OUTCOME OF DISTAL END TIBIA FRACTURES MANAGED

BY MINIMALLY INVASIVE PLATE OSTEOSYNTHESIS

TECHNIQUE

Dr sagar tomarLlrm medical college meerut up

INTRODUCTION

Earlier the treatment of distal tibia was done using intramedullary osteosynthesis but it does not provide a stable rigid fixation

open reduction and internal fixation was attempted with classical plates but it requires a quite larger incision causing larger periosteal damage

This Traditional ORIF results in extensive

soft tissue dissection and periosteal injury and are associated with high rates of infection delayed union and non‐union

Because of these drawbacks research and development leads to the invention of new plates called ldquoBIOLOGICAL PLATErdquo and new surgical procedures one of which is ldquoMINIMALLY INVASIVE PLATE OSTEOSYNTHESISrdquo

MIPO technique

In this technique only the normal bone cortexes both proximal and distal to the fracture site are exposed for positioning the plate and inserting the screws while the fracture site is not explored so that osteogenic tissues surrounding the fracture are well protected and their blood supply is also well preserved

biomechanics

Mipo relies on relative stability rather than absolute rigid fixation because of which micromotion is produced at the fracture site and a larger and rapid callus formation occurs leading to rapid bone healing

Relative stability does not require accurate apposition of fragments as the gap are filled up by bridging callus

Indication of mipo in distal tibial

intraarticular or periarticular fractures which

are considered unsuitable for intramedullary nailing

They include

Communited fractures

low-grade open fractures of the distal tibia

displaced pilon fractures with sufficient medial soft-tissue coverage to allow articular reconstruction and percutaneous plating

unstable distal metaphyseal and diaphyseal fractures

Contra-indication

MIPO is contraindicated in situations where the medial soft tissue is compromised such as in severe open fractures or badly contused skin

If the bone is osteoporotic or comminution is so excessive that surgery cannot restore or stabilize the joint then other methods of treatment must be sought such as external fixator

In severely shattered pilon fractures when only choice is external fixator

Advantage of mipo

minimizes risk of soft tissue damage

preserve vascular supply to bone and soft tissue

decrease periosteum damage

have better and faster callus formation

have better healing and union rate

decrease complication of infection and re-fracture

decrease the use of supplementary bone grafting

IMPLANT CHOICE

Choice of implant could be

bullMetaphysealplate (broad or narrow)

bullPrecountoureddistal tibia locking plate

bullClowerleaf LCP

procedure

POSITIONING OF PATIENT

INCISION

anteromedial approach a 2ndash3 cm incision is made starting at the level of the tibial plafond and extending proximally along the medial surface of the distal tibia ORposteromedial incision along the

posterior border of medialmalleolus about 4ndash5 cm in length and slightly curved can beused

PRELIMINARY REDUCTION

REDUCTION COULD BE BY MANUAL TRACTION OR BY USE OF DISTRACTOR AND REDUCTION FORCEPS PERCUTANEOUSLY

PLATE INSERTION

PLATE COULD BE INSERTED WITH HELP OF INSERTION DEVICE OR WITH HELP OF LOCKING SLEEVE UNDER SUBMUSCULAR PLANE

PRELIMINARY PLATE STABILIZATION

BY USE OF K-WIRE FOR TEMPORARY FIXATION OF PLATE

PLATE FIXATION

A MINIMUM OF 6 CORTICES ON BOTH SIDE OF FRACTURE ARE USED AND INTERFRAGMENATRY COMPRESSION SCREW WHERE NEEDED

REVIEW OF WORK

THE VARIOUS STUDY DONE TO CHECK THE EFFECTIVENESS OF MIPO TECHNIQUE FOR DISTAL END TIBIA FRACTURES ARE AS FOLLOWS

REVIEW OF WORK

STUDY NO OF FRACTURE

FIXATION OUTCOME COMPLICATION

Ronga M et al2010

19 MIPO Union 18 (223 wks range 12-24)

Nonunion1 No malunion ( ge7deg deformity or ge1 cm LLD) Deep infection3

Ahmad MA et al 2010

18 MIPO Union 15 (212 wks)

Delayed union 3 Superficial wound infarction 1 Chronic wound infection 1 Implant failure 1

Ronga M Longo UG Maffulli N Minimally invasive locked plating of distal tibia fractures is safe and effective Clin Orthop Relat Res 2010

Ahmad MA Sivaraman A Zia A Rai A Patel AD Percutaneouslocking plates for fractures of the distal tibia Our experience and a review of the literature J Trauma 2010

HasenbohehlerE et al (2007)

32 (open fracture 8)

MIPO Union 29 ( 277 wks range 24ndash60)

Nonunion 2 No malunion (ge 5deg deformity or ge 1 cm LLD) Plate bending (18deg) 1 Pseudoarthrosis 2

Hazarika S et al (2006)

20 (open fracture 8)

MIPO Union 18 ( 285 wks range 9ndash68)

Nonunion 2 Delayed wound break down 2 Wound infection 1 Implant failure 1 Secondary procedure 2

Hasenboehler E RikliD Babst R Locking compression plate with minimally invasive plate osteosynthesis in diaphyseal and distal tibial fracture a retrospective study of 32 patients Injury 2007

Hazarika S Chakravarthy J Cooper J Minimally invasive locking plate osteosynthesis for fractures of the distal tibia-results in 20 patients Injury 2006

Bahari S et al (2007)

42 (open fracture 8)

MIPO Union 42 (224 wks)

No malunionSuperficial wound infection 2 Deep infection 1 Implant failure 1

Collinge C et al(2010)

38 (open fracture 8)

MIPO Union 38 (21 wks range 9ndash48)

Malunion ( ge 5degdeformity) 1 Secondary procedure 3

Mushtaq A et al (2009)

21 (open fracture 4)

MIPO Union 21( 55 months range 3ndash13)

Delayed union 1 Non union 1 Wound infection 2 Secondary procedure 2

Bahari S LenehanB Khan H Mcelwain JP Minimally invasive percutaneous plate fixation of distal tibia fractures Acta Orthop Belg2007

Collinge C Protzman R Outcomes of minimally invasive plate osteosynthesis for metaphyseal distal tibia fractures J OrthopTrauma 2010

Mushtaq A Shahid R AsifM Maqsood M Distal tibialfracture fixation with locking compression plate (LCP) using the minimally invasive percutaneousosteosynthesis (MIPO) technique Eur J Trauma Emerg Surg 2009

Lau TW et al (2008)

48 (open fracture 9)

MIPO Union 47 ( 187 wks range 12-44 wks)

Delayed union 5 Wound infection 8 Secondary procedure1

Gupta RK et al(2010)

80 (open fracture19)

MIPO Union 77 (19 wks range 16-32)

Delayed union 7 Non union 3 Malunion (ge 5degdeformity or ge 1 cm LLD) 2 Wound infection1 Wound breakdown 2 Secondary procedure 2

Lau TW Leung F Chan CF Chow SP Wound complication of minimally invasive plate osteosynthesis in distal tibia fractures Inter Orthop 2008

Gupta RK RohillaRK Sangwan K Singh V Walia S Locking plate fixation in distal metaphysealtibial fractures series of 79 patients Inter Orthop 2010

Shreshta et al(2011)

20 MIPO Union 20 (185 wks range 14-28)

Delayed union 1 No malunion (ge 5deg deformity or ge 1 cm LLD) Superficial wound infection 2 Deep infection 1 Secondary procedure 1

Oog Jin et al 10 MIPO Union10(21 wksrange17-28)

no non-union no angular deformity gt 5deg shortening gt 10 mm no infection

Shrestha D Acharya BM Shrestha PM Minimally invasive plate osteosynthesis with locking compression plate for distal diametaphyseal tibia fracture Kathmandu Univ Med J 2011

hong et al

Fractures of the Distal Tibia Treated with PolyaxialLocking Plating

Hong Gao MD Chang-Qing Zhang MD PhD Cong-FengLuo MD PhD Zu-Bin Zhou MD and Bing-Fang Zeng

MDClin Orthop Relat Res 2009 March 467(3) 831ndash837 Total pts 32 The average healing time was 13 weeks (range 10ndash18 weeks)

for fractures using the MIPO technique and 156 weeks (range 10ndash20 weeks p = 00045) for fractures using the ORIF technique

The fracture healing time was shorter in the MIPO technique group than in the ORIF technique group which might be related to minimizing soft tissue trauma to the injured zone and preserving better blood supply around the fracture area

INTRODUCTION

Earlier the treatment of distal tibia was done using intramedullary osteosynthesis but it does not provide a stable rigid fixation

open reduction and internal fixation was attempted with classical plates but it requires a quite larger incision causing larger periosteal damage

This Traditional ORIF results in extensive

soft tissue dissection and periosteal injury and are associated with high rates of infection delayed union and non‐union

Because of these drawbacks research and development leads to the invention of new plates called ldquoBIOLOGICAL PLATErdquo and new surgical procedures one of which is ldquoMINIMALLY INVASIVE PLATE OSTEOSYNTHESISrdquo

MIPO technique

In this technique only the normal bone cortexes both proximal and distal to the fracture site are exposed for positioning the plate and inserting the screws while the fracture site is not explored so that osteogenic tissues surrounding the fracture are well protected and their blood supply is also well preserved

biomechanics

Mipo relies on relative stability rather than absolute rigid fixation because of which micromotion is produced at the fracture site and a larger and rapid callus formation occurs leading to rapid bone healing

Relative stability does not require accurate apposition of fragments as the gap are filled up by bridging callus

Indication of mipo in distal tibial

intraarticular or periarticular fractures which

are considered unsuitable for intramedullary nailing

They include

Communited fractures

low-grade open fractures of the distal tibia

displaced pilon fractures with sufficient medial soft-tissue coverage to allow articular reconstruction and percutaneous plating

unstable distal metaphyseal and diaphyseal fractures

Contra-indication

MIPO is contraindicated in situations where the medial soft tissue is compromised such as in severe open fractures or badly contused skin

If the bone is osteoporotic or comminution is so excessive that surgery cannot restore or stabilize the joint then other methods of treatment must be sought such as external fixator

In severely shattered pilon fractures when only choice is external fixator

Advantage of mipo

minimizes risk of soft tissue damage

preserve vascular supply to bone and soft tissue

decrease periosteum damage

have better and faster callus formation

have better healing and union rate

decrease complication of infection and re-fracture

decrease the use of supplementary bone grafting

IMPLANT CHOICE

Choice of implant could be

bullMetaphysealplate (broad or narrow)

bullPrecountoureddistal tibia locking plate

bullClowerleaf LCP

procedure

POSITIONING OF PATIENT

INCISION

anteromedial approach a 2ndash3 cm incision is made starting at the level of the tibial plafond and extending proximally along the medial surface of the distal tibia ORposteromedial incision along the

posterior border of medialmalleolus about 4ndash5 cm in length and slightly curved can beused

PRELIMINARY REDUCTION

REDUCTION COULD BE BY MANUAL TRACTION OR BY USE OF DISTRACTOR AND REDUCTION FORCEPS PERCUTANEOUSLY

PLATE INSERTION

PLATE COULD BE INSERTED WITH HELP OF INSERTION DEVICE OR WITH HELP OF LOCKING SLEEVE UNDER SUBMUSCULAR PLANE

PRELIMINARY PLATE STABILIZATION

BY USE OF K-WIRE FOR TEMPORARY FIXATION OF PLATE

PLATE FIXATION

A MINIMUM OF 6 CORTICES ON BOTH SIDE OF FRACTURE ARE USED AND INTERFRAGMENATRY COMPRESSION SCREW WHERE NEEDED

REVIEW OF WORK

THE VARIOUS STUDY DONE TO CHECK THE EFFECTIVENESS OF MIPO TECHNIQUE FOR DISTAL END TIBIA FRACTURES ARE AS FOLLOWS

REVIEW OF WORK

STUDY NO OF FRACTURE

FIXATION OUTCOME COMPLICATION

Ronga M et al2010

19 MIPO Union 18 (223 wks range 12-24)

Nonunion1 No malunion ( ge7deg deformity or ge1 cm LLD) Deep infection3

Ahmad MA et al 2010

18 MIPO Union 15 (212 wks)

Delayed union 3 Superficial wound infarction 1 Chronic wound infection 1 Implant failure 1

Ronga M Longo UG Maffulli N Minimally invasive locked plating of distal tibia fractures is safe and effective Clin Orthop Relat Res 2010

Ahmad MA Sivaraman A Zia A Rai A Patel AD Percutaneouslocking plates for fractures of the distal tibia Our experience and a review of the literature J Trauma 2010

HasenbohehlerE et al (2007)

32 (open fracture 8)

MIPO Union 29 ( 277 wks range 24ndash60)

Nonunion 2 No malunion (ge 5deg deformity or ge 1 cm LLD) Plate bending (18deg) 1 Pseudoarthrosis 2

Hazarika S et al (2006)

20 (open fracture 8)

MIPO Union 18 ( 285 wks range 9ndash68)

Nonunion 2 Delayed wound break down 2 Wound infection 1 Implant failure 1 Secondary procedure 2

Hasenboehler E RikliD Babst R Locking compression plate with minimally invasive plate osteosynthesis in diaphyseal and distal tibial fracture a retrospective study of 32 patients Injury 2007

Hazarika S Chakravarthy J Cooper J Minimally invasive locking plate osteosynthesis for fractures of the distal tibia-results in 20 patients Injury 2006

Bahari S et al (2007)

42 (open fracture 8)

MIPO Union 42 (224 wks)

No malunionSuperficial wound infection 2 Deep infection 1 Implant failure 1

Collinge C et al(2010)

38 (open fracture 8)

MIPO Union 38 (21 wks range 9ndash48)

Malunion ( ge 5degdeformity) 1 Secondary procedure 3

Mushtaq A et al (2009)

21 (open fracture 4)

MIPO Union 21( 55 months range 3ndash13)

Delayed union 1 Non union 1 Wound infection 2 Secondary procedure 2

Bahari S LenehanB Khan H Mcelwain JP Minimally invasive percutaneous plate fixation of distal tibia fractures Acta Orthop Belg2007

Collinge C Protzman R Outcomes of minimally invasive plate osteosynthesis for metaphyseal distal tibia fractures J OrthopTrauma 2010

Mushtaq A Shahid R AsifM Maqsood M Distal tibialfracture fixation with locking compression plate (LCP) using the minimally invasive percutaneousosteosynthesis (MIPO) technique Eur J Trauma Emerg Surg 2009

Lau TW et al (2008)

48 (open fracture 9)

MIPO Union 47 ( 187 wks range 12-44 wks)

Delayed union 5 Wound infection 8 Secondary procedure1

Gupta RK et al(2010)

80 (open fracture19)

MIPO Union 77 (19 wks range 16-32)

Delayed union 7 Non union 3 Malunion (ge 5degdeformity or ge 1 cm LLD) 2 Wound infection1 Wound breakdown 2 Secondary procedure 2

Lau TW Leung F Chan CF Chow SP Wound complication of minimally invasive plate osteosynthesis in distal tibia fractures Inter Orthop 2008

Gupta RK RohillaRK Sangwan K Singh V Walia S Locking plate fixation in distal metaphysealtibial fractures series of 79 patients Inter Orthop 2010

Shreshta et al(2011)

20 MIPO Union 20 (185 wks range 14-28)

Delayed union 1 No malunion (ge 5deg deformity or ge 1 cm LLD) Superficial wound infection 2 Deep infection 1 Secondary procedure 1

Oog Jin et al 10 MIPO Union10(21 wksrange17-28)

no non-union no angular deformity gt 5deg shortening gt 10 mm no infection

Shrestha D Acharya BM Shrestha PM Minimally invasive plate osteosynthesis with locking compression plate for distal diametaphyseal tibia fracture Kathmandu Univ Med J 2011

hong et al

Fractures of the Distal Tibia Treated with PolyaxialLocking Plating

Hong Gao MD Chang-Qing Zhang MD PhD Cong-FengLuo MD PhD Zu-Bin Zhou MD and Bing-Fang Zeng

MDClin Orthop Relat Res 2009 March 467(3) 831ndash837 Total pts 32 The average healing time was 13 weeks (range 10ndash18 weeks)

for fractures using the MIPO technique and 156 weeks (range 10ndash20 weeks p = 00045) for fractures using the ORIF technique

The fracture healing time was shorter in the MIPO technique group than in the ORIF technique group which might be related to minimizing soft tissue trauma to the injured zone and preserving better blood supply around the fracture area

Because of these drawbacks research and development leads to the invention of new plates called ldquoBIOLOGICAL PLATErdquo and new surgical procedures one of which is ldquoMINIMALLY INVASIVE PLATE OSTEOSYNTHESISrdquo

MIPO technique

In this technique only the normal bone cortexes both proximal and distal to the fracture site are exposed for positioning the plate and inserting the screws while the fracture site is not explored so that osteogenic tissues surrounding the fracture are well protected and their blood supply is also well preserved

biomechanics

Mipo relies on relative stability rather than absolute rigid fixation because of which micromotion is produced at the fracture site and a larger and rapid callus formation occurs leading to rapid bone healing

Relative stability does not require accurate apposition of fragments as the gap are filled up by bridging callus

Indication of mipo in distal tibial

intraarticular or periarticular fractures which

are considered unsuitable for intramedullary nailing

They include

Communited fractures

low-grade open fractures of the distal tibia

displaced pilon fractures with sufficient medial soft-tissue coverage to allow articular reconstruction and percutaneous plating

unstable distal metaphyseal and diaphyseal fractures

Contra-indication

MIPO is contraindicated in situations where the medial soft tissue is compromised such as in severe open fractures or badly contused skin

If the bone is osteoporotic or comminution is so excessive that surgery cannot restore or stabilize the joint then other methods of treatment must be sought such as external fixator

In severely shattered pilon fractures when only choice is external fixator

Advantage of mipo

minimizes risk of soft tissue damage

preserve vascular supply to bone and soft tissue

decrease periosteum damage

have better and faster callus formation

have better healing and union rate

decrease complication of infection and re-fracture

decrease the use of supplementary bone grafting

IMPLANT CHOICE

Choice of implant could be

bullMetaphysealplate (broad or narrow)

bullPrecountoureddistal tibia locking plate

bullClowerleaf LCP

procedure

POSITIONING OF PATIENT

INCISION

anteromedial approach a 2ndash3 cm incision is made starting at the level of the tibial plafond and extending proximally along the medial surface of the distal tibia ORposteromedial incision along the

posterior border of medialmalleolus about 4ndash5 cm in length and slightly curved can beused

PRELIMINARY REDUCTION

REDUCTION COULD BE BY MANUAL TRACTION OR BY USE OF DISTRACTOR AND REDUCTION FORCEPS PERCUTANEOUSLY

PLATE INSERTION

PLATE COULD BE INSERTED WITH HELP OF INSERTION DEVICE OR WITH HELP OF LOCKING SLEEVE UNDER SUBMUSCULAR PLANE

PRELIMINARY PLATE STABILIZATION

BY USE OF K-WIRE FOR TEMPORARY FIXATION OF PLATE

PLATE FIXATION

A MINIMUM OF 6 CORTICES ON BOTH SIDE OF FRACTURE ARE USED AND INTERFRAGMENATRY COMPRESSION SCREW WHERE NEEDED

REVIEW OF WORK

THE VARIOUS STUDY DONE TO CHECK THE EFFECTIVENESS OF MIPO TECHNIQUE FOR DISTAL END TIBIA FRACTURES ARE AS FOLLOWS

REVIEW OF WORK

STUDY NO OF FRACTURE

FIXATION OUTCOME COMPLICATION

Ronga M et al2010

19 MIPO Union 18 (223 wks range 12-24)

Nonunion1 No malunion ( ge7deg deformity or ge1 cm LLD) Deep infection3

Ahmad MA et al 2010

18 MIPO Union 15 (212 wks)

Delayed union 3 Superficial wound infarction 1 Chronic wound infection 1 Implant failure 1

Ronga M Longo UG Maffulli N Minimally invasive locked plating of distal tibia fractures is safe and effective Clin Orthop Relat Res 2010

Ahmad MA Sivaraman A Zia A Rai A Patel AD Percutaneouslocking plates for fractures of the distal tibia Our experience and a review of the literature J Trauma 2010

HasenbohehlerE et al (2007)

32 (open fracture 8)

MIPO Union 29 ( 277 wks range 24ndash60)

Nonunion 2 No malunion (ge 5deg deformity or ge 1 cm LLD) Plate bending (18deg) 1 Pseudoarthrosis 2

Hazarika S et al (2006)

20 (open fracture 8)

MIPO Union 18 ( 285 wks range 9ndash68)

Nonunion 2 Delayed wound break down 2 Wound infection 1 Implant failure 1 Secondary procedure 2

Hasenboehler E RikliD Babst R Locking compression plate with minimally invasive plate osteosynthesis in diaphyseal and distal tibial fracture a retrospective study of 32 patients Injury 2007

Hazarika S Chakravarthy J Cooper J Minimally invasive locking plate osteosynthesis for fractures of the distal tibia-results in 20 patients Injury 2006

Bahari S et al (2007)

42 (open fracture 8)

MIPO Union 42 (224 wks)

No malunionSuperficial wound infection 2 Deep infection 1 Implant failure 1

Collinge C et al(2010)

38 (open fracture 8)

MIPO Union 38 (21 wks range 9ndash48)

Malunion ( ge 5degdeformity) 1 Secondary procedure 3

Mushtaq A et al (2009)

21 (open fracture 4)

MIPO Union 21( 55 months range 3ndash13)

Delayed union 1 Non union 1 Wound infection 2 Secondary procedure 2

Bahari S LenehanB Khan H Mcelwain JP Minimally invasive percutaneous plate fixation of distal tibia fractures Acta Orthop Belg2007

Collinge C Protzman R Outcomes of minimally invasive plate osteosynthesis for metaphyseal distal tibia fractures J OrthopTrauma 2010

Mushtaq A Shahid R AsifM Maqsood M Distal tibialfracture fixation with locking compression plate (LCP) using the minimally invasive percutaneousosteosynthesis (MIPO) technique Eur J Trauma Emerg Surg 2009

Lau TW et al (2008)

48 (open fracture 9)

MIPO Union 47 ( 187 wks range 12-44 wks)

Delayed union 5 Wound infection 8 Secondary procedure1

Gupta RK et al(2010)

80 (open fracture19)

MIPO Union 77 (19 wks range 16-32)

Delayed union 7 Non union 3 Malunion (ge 5degdeformity or ge 1 cm LLD) 2 Wound infection1 Wound breakdown 2 Secondary procedure 2

Lau TW Leung F Chan CF Chow SP Wound complication of minimally invasive plate osteosynthesis in distal tibia fractures Inter Orthop 2008

Gupta RK RohillaRK Sangwan K Singh V Walia S Locking plate fixation in distal metaphysealtibial fractures series of 79 patients Inter Orthop 2010

Shreshta et al(2011)

20 MIPO Union 20 (185 wks range 14-28)

Delayed union 1 No malunion (ge 5deg deformity or ge 1 cm LLD) Superficial wound infection 2 Deep infection 1 Secondary procedure 1

Oog Jin et al 10 MIPO Union10(21 wksrange17-28)

no non-union no angular deformity gt 5deg shortening gt 10 mm no infection

Shrestha D Acharya BM Shrestha PM Minimally invasive plate osteosynthesis with locking compression plate for distal diametaphyseal tibia fracture Kathmandu Univ Med J 2011

hong et al

Fractures of the Distal Tibia Treated with PolyaxialLocking Plating

Hong Gao MD Chang-Qing Zhang MD PhD Cong-FengLuo MD PhD Zu-Bin Zhou MD and Bing-Fang Zeng

MDClin Orthop Relat Res 2009 March 467(3) 831ndash837 Total pts 32 The average healing time was 13 weeks (range 10ndash18 weeks)

for fractures using the MIPO technique and 156 weeks (range 10ndash20 weeks p = 00045) for fractures using the ORIF technique

The fracture healing time was shorter in the MIPO technique group than in the ORIF technique group which might be related to minimizing soft tissue trauma to the injured zone and preserving better blood supply around the fracture area

MIPO technique

In this technique only the normal bone cortexes both proximal and distal to the fracture site are exposed for positioning the plate and inserting the screws while the fracture site is not explored so that osteogenic tissues surrounding the fracture are well protected and their blood supply is also well preserved

biomechanics

Mipo relies on relative stability rather than absolute rigid fixation because of which micromotion is produced at the fracture site and a larger and rapid callus formation occurs leading to rapid bone healing

Relative stability does not require accurate apposition of fragments as the gap are filled up by bridging callus

Indication of mipo in distal tibial

intraarticular or periarticular fractures which

are considered unsuitable for intramedullary nailing

They include

Communited fractures

low-grade open fractures of the distal tibia

displaced pilon fractures with sufficient medial soft-tissue coverage to allow articular reconstruction and percutaneous plating

unstable distal metaphyseal and diaphyseal fractures

Contra-indication

MIPO is contraindicated in situations where the medial soft tissue is compromised such as in severe open fractures or badly contused skin

If the bone is osteoporotic or comminution is so excessive that surgery cannot restore or stabilize the joint then other methods of treatment must be sought such as external fixator

In severely shattered pilon fractures when only choice is external fixator

Advantage of mipo

minimizes risk of soft tissue damage

preserve vascular supply to bone and soft tissue

decrease periosteum damage

have better and faster callus formation

have better healing and union rate

decrease complication of infection and re-fracture

decrease the use of supplementary bone grafting

IMPLANT CHOICE

Choice of implant could be

bullMetaphysealplate (broad or narrow)

bullPrecountoureddistal tibia locking plate

bullClowerleaf LCP

procedure

POSITIONING OF PATIENT

INCISION

anteromedial approach a 2ndash3 cm incision is made starting at the level of the tibial plafond and extending proximally along the medial surface of the distal tibia ORposteromedial incision along the

posterior border of medialmalleolus about 4ndash5 cm in length and slightly curved can beused

PRELIMINARY REDUCTION

REDUCTION COULD BE BY MANUAL TRACTION OR BY USE OF DISTRACTOR AND REDUCTION FORCEPS PERCUTANEOUSLY

PLATE INSERTION

PLATE COULD BE INSERTED WITH HELP OF INSERTION DEVICE OR WITH HELP OF LOCKING SLEEVE UNDER SUBMUSCULAR PLANE

PRELIMINARY PLATE STABILIZATION

BY USE OF K-WIRE FOR TEMPORARY FIXATION OF PLATE

PLATE FIXATION

A MINIMUM OF 6 CORTICES ON BOTH SIDE OF FRACTURE ARE USED AND INTERFRAGMENATRY COMPRESSION SCREW WHERE NEEDED

REVIEW OF WORK

THE VARIOUS STUDY DONE TO CHECK THE EFFECTIVENESS OF MIPO TECHNIQUE FOR DISTAL END TIBIA FRACTURES ARE AS FOLLOWS

REVIEW OF WORK

STUDY NO OF FRACTURE

FIXATION OUTCOME COMPLICATION

Ronga M et al2010

19 MIPO Union 18 (223 wks range 12-24)

Nonunion1 No malunion ( ge7deg deformity or ge1 cm LLD) Deep infection3

Ahmad MA et al 2010

18 MIPO Union 15 (212 wks)

Delayed union 3 Superficial wound infarction 1 Chronic wound infection 1 Implant failure 1

Ronga M Longo UG Maffulli N Minimally invasive locked plating of distal tibia fractures is safe and effective Clin Orthop Relat Res 2010

Ahmad MA Sivaraman A Zia A Rai A Patel AD Percutaneouslocking plates for fractures of the distal tibia Our experience and a review of the literature J Trauma 2010

HasenbohehlerE et al (2007)

32 (open fracture 8)

MIPO Union 29 ( 277 wks range 24ndash60)

Nonunion 2 No malunion (ge 5deg deformity or ge 1 cm LLD) Plate bending (18deg) 1 Pseudoarthrosis 2

Hazarika S et al (2006)

20 (open fracture 8)

MIPO Union 18 ( 285 wks range 9ndash68)

Nonunion 2 Delayed wound break down 2 Wound infection 1 Implant failure 1 Secondary procedure 2

Hasenboehler E RikliD Babst R Locking compression plate with minimally invasive plate osteosynthesis in diaphyseal and distal tibial fracture a retrospective study of 32 patients Injury 2007

Hazarika S Chakravarthy J Cooper J Minimally invasive locking plate osteosynthesis for fractures of the distal tibia-results in 20 patients Injury 2006

Bahari S et al (2007)

42 (open fracture 8)

MIPO Union 42 (224 wks)

No malunionSuperficial wound infection 2 Deep infection 1 Implant failure 1

Collinge C et al(2010)

38 (open fracture 8)

MIPO Union 38 (21 wks range 9ndash48)

Malunion ( ge 5degdeformity) 1 Secondary procedure 3

Mushtaq A et al (2009)

21 (open fracture 4)

MIPO Union 21( 55 months range 3ndash13)

Delayed union 1 Non union 1 Wound infection 2 Secondary procedure 2

Bahari S LenehanB Khan H Mcelwain JP Minimally invasive percutaneous plate fixation of distal tibia fractures Acta Orthop Belg2007

Collinge C Protzman R Outcomes of minimally invasive plate osteosynthesis for metaphyseal distal tibia fractures J OrthopTrauma 2010

Mushtaq A Shahid R AsifM Maqsood M Distal tibialfracture fixation with locking compression plate (LCP) using the minimally invasive percutaneousosteosynthesis (MIPO) technique Eur J Trauma Emerg Surg 2009

Lau TW et al (2008)

48 (open fracture 9)

MIPO Union 47 ( 187 wks range 12-44 wks)

Delayed union 5 Wound infection 8 Secondary procedure1

Gupta RK et al(2010)

80 (open fracture19)

MIPO Union 77 (19 wks range 16-32)

Delayed union 7 Non union 3 Malunion (ge 5degdeformity or ge 1 cm LLD) 2 Wound infection1 Wound breakdown 2 Secondary procedure 2

Lau TW Leung F Chan CF Chow SP Wound complication of minimally invasive plate osteosynthesis in distal tibia fractures Inter Orthop 2008

Gupta RK RohillaRK Sangwan K Singh V Walia S Locking plate fixation in distal metaphysealtibial fractures series of 79 patients Inter Orthop 2010

Shreshta et al(2011)

20 MIPO Union 20 (185 wks range 14-28)

Delayed union 1 No malunion (ge 5deg deformity or ge 1 cm LLD) Superficial wound infection 2 Deep infection 1 Secondary procedure 1

Oog Jin et al 10 MIPO Union10(21 wksrange17-28)

no non-union no angular deformity gt 5deg shortening gt 10 mm no infection

Shrestha D Acharya BM Shrestha PM Minimally invasive plate osteosynthesis with locking compression plate for distal diametaphyseal tibia fracture Kathmandu Univ Med J 2011

hong et al

Fractures of the Distal Tibia Treated with PolyaxialLocking Plating

Hong Gao MD Chang-Qing Zhang MD PhD Cong-FengLuo MD PhD Zu-Bin Zhou MD and Bing-Fang Zeng

MDClin Orthop Relat Res 2009 March 467(3) 831ndash837 Total pts 32 The average healing time was 13 weeks (range 10ndash18 weeks)

for fractures using the MIPO technique and 156 weeks (range 10ndash20 weeks p = 00045) for fractures using the ORIF technique

The fracture healing time was shorter in the MIPO technique group than in the ORIF technique group which might be related to minimizing soft tissue trauma to the injured zone and preserving better blood supply around the fracture area

biomechanics

Mipo relies on relative stability rather than absolute rigid fixation because of which micromotion is produced at the fracture site and a larger and rapid callus formation occurs leading to rapid bone healing

Relative stability does not require accurate apposition of fragments as the gap are filled up by bridging callus

Indication of mipo in distal tibial

intraarticular or periarticular fractures which

are considered unsuitable for intramedullary nailing

They include

Communited fractures

low-grade open fractures of the distal tibia

displaced pilon fractures with sufficient medial soft-tissue coverage to allow articular reconstruction and percutaneous plating

unstable distal metaphyseal and diaphyseal fractures

Contra-indication

MIPO is contraindicated in situations where the medial soft tissue is compromised such as in severe open fractures or badly contused skin

If the bone is osteoporotic or comminution is so excessive that surgery cannot restore or stabilize the joint then other methods of treatment must be sought such as external fixator

In severely shattered pilon fractures when only choice is external fixator

Advantage of mipo

minimizes risk of soft tissue damage

preserve vascular supply to bone and soft tissue

decrease periosteum damage

have better and faster callus formation

have better healing and union rate

decrease complication of infection and re-fracture

decrease the use of supplementary bone grafting

IMPLANT CHOICE

Choice of implant could be

bullMetaphysealplate (broad or narrow)

bullPrecountoureddistal tibia locking plate

bullClowerleaf LCP

procedure

POSITIONING OF PATIENT

INCISION

anteromedial approach a 2ndash3 cm incision is made starting at the level of the tibial plafond and extending proximally along the medial surface of the distal tibia ORposteromedial incision along the

posterior border of medialmalleolus about 4ndash5 cm in length and slightly curved can beused

PRELIMINARY REDUCTION

REDUCTION COULD BE BY MANUAL TRACTION OR BY USE OF DISTRACTOR AND REDUCTION FORCEPS PERCUTANEOUSLY

PLATE INSERTION

PLATE COULD BE INSERTED WITH HELP OF INSERTION DEVICE OR WITH HELP OF LOCKING SLEEVE UNDER SUBMUSCULAR PLANE

PRELIMINARY PLATE STABILIZATION

BY USE OF K-WIRE FOR TEMPORARY FIXATION OF PLATE

PLATE FIXATION

A MINIMUM OF 6 CORTICES ON BOTH SIDE OF FRACTURE ARE USED AND INTERFRAGMENATRY COMPRESSION SCREW WHERE NEEDED

REVIEW OF WORK

THE VARIOUS STUDY DONE TO CHECK THE EFFECTIVENESS OF MIPO TECHNIQUE FOR DISTAL END TIBIA FRACTURES ARE AS FOLLOWS

REVIEW OF WORK

STUDY NO OF FRACTURE

FIXATION OUTCOME COMPLICATION

Ronga M et al2010

19 MIPO Union 18 (223 wks range 12-24)

Nonunion1 No malunion ( ge7deg deformity or ge1 cm LLD) Deep infection3

Ahmad MA et al 2010

18 MIPO Union 15 (212 wks)

Delayed union 3 Superficial wound infarction 1 Chronic wound infection 1 Implant failure 1

Ronga M Longo UG Maffulli N Minimally invasive locked plating of distal tibia fractures is safe and effective Clin Orthop Relat Res 2010

Ahmad MA Sivaraman A Zia A Rai A Patel AD Percutaneouslocking plates for fractures of the distal tibia Our experience and a review of the literature J Trauma 2010

HasenbohehlerE et al (2007)

32 (open fracture 8)

MIPO Union 29 ( 277 wks range 24ndash60)

Nonunion 2 No malunion (ge 5deg deformity or ge 1 cm LLD) Plate bending (18deg) 1 Pseudoarthrosis 2

Hazarika S et al (2006)

20 (open fracture 8)

MIPO Union 18 ( 285 wks range 9ndash68)

Nonunion 2 Delayed wound break down 2 Wound infection 1 Implant failure 1 Secondary procedure 2

Hasenboehler E RikliD Babst R Locking compression plate with minimally invasive plate osteosynthesis in diaphyseal and distal tibial fracture a retrospective study of 32 patients Injury 2007

Hazarika S Chakravarthy J Cooper J Minimally invasive locking plate osteosynthesis for fractures of the distal tibia-results in 20 patients Injury 2006

Bahari S et al (2007)

42 (open fracture 8)

MIPO Union 42 (224 wks)

No malunionSuperficial wound infection 2 Deep infection 1 Implant failure 1

Collinge C et al(2010)

38 (open fracture 8)

MIPO Union 38 (21 wks range 9ndash48)

Malunion ( ge 5degdeformity) 1 Secondary procedure 3

Mushtaq A et al (2009)

21 (open fracture 4)

MIPO Union 21( 55 months range 3ndash13)

Delayed union 1 Non union 1 Wound infection 2 Secondary procedure 2

Bahari S LenehanB Khan H Mcelwain JP Minimally invasive percutaneous plate fixation of distal tibia fractures Acta Orthop Belg2007

Collinge C Protzman R Outcomes of minimally invasive plate osteosynthesis for metaphyseal distal tibia fractures J OrthopTrauma 2010

Mushtaq A Shahid R AsifM Maqsood M Distal tibialfracture fixation with locking compression plate (LCP) using the minimally invasive percutaneousosteosynthesis (MIPO) technique Eur J Trauma Emerg Surg 2009

Lau TW et al (2008)

48 (open fracture 9)

MIPO Union 47 ( 187 wks range 12-44 wks)

Delayed union 5 Wound infection 8 Secondary procedure1

Gupta RK et al(2010)

80 (open fracture19)

MIPO Union 77 (19 wks range 16-32)

Delayed union 7 Non union 3 Malunion (ge 5degdeformity or ge 1 cm LLD) 2 Wound infection1 Wound breakdown 2 Secondary procedure 2

Lau TW Leung F Chan CF Chow SP Wound complication of minimally invasive plate osteosynthesis in distal tibia fractures Inter Orthop 2008

Gupta RK RohillaRK Sangwan K Singh V Walia S Locking plate fixation in distal metaphysealtibial fractures series of 79 patients Inter Orthop 2010

Shreshta et al(2011)

20 MIPO Union 20 (185 wks range 14-28)

Delayed union 1 No malunion (ge 5deg deformity or ge 1 cm LLD) Superficial wound infection 2 Deep infection 1 Secondary procedure 1

Oog Jin et al 10 MIPO Union10(21 wksrange17-28)

no non-union no angular deformity gt 5deg shortening gt 10 mm no infection

Shrestha D Acharya BM Shrestha PM Minimally invasive plate osteosynthesis with locking compression plate for distal diametaphyseal tibia fracture Kathmandu Univ Med J 2011

hong et al

Fractures of the Distal Tibia Treated with PolyaxialLocking Plating

Hong Gao MD Chang-Qing Zhang MD PhD Cong-FengLuo MD PhD Zu-Bin Zhou MD and Bing-Fang Zeng

MDClin Orthop Relat Res 2009 March 467(3) 831ndash837 Total pts 32 The average healing time was 13 weeks (range 10ndash18 weeks)

for fractures using the MIPO technique and 156 weeks (range 10ndash20 weeks p = 00045) for fractures using the ORIF technique

The fracture healing time was shorter in the MIPO technique group than in the ORIF technique group which might be related to minimizing soft tissue trauma to the injured zone and preserving better blood supply around the fracture area

Indication of mipo in distal tibial

intraarticular or periarticular fractures which

are considered unsuitable for intramedullary nailing

They include

Communited fractures

low-grade open fractures of the distal tibia

displaced pilon fractures with sufficient medial soft-tissue coverage to allow articular reconstruction and percutaneous plating

unstable distal metaphyseal and diaphyseal fractures

Contra-indication

MIPO is contraindicated in situations where the medial soft tissue is compromised such as in severe open fractures or badly contused skin

If the bone is osteoporotic or comminution is so excessive that surgery cannot restore or stabilize the joint then other methods of treatment must be sought such as external fixator

In severely shattered pilon fractures when only choice is external fixator

Advantage of mipo

minimizes risk of soft tissue damage

preserve vascular supply to bone and soft tissue

decrease periosteum damage

have better and faster callus formation

have better healing and union rate

decrease complication of infection and re-fracture

decrease the use of supplementary bone grafting

IMPLANT CHOICE

Choice of implant could be

bullMetaphysealplate (broad or narrow)

bullPrecountoureddistal tibia locking plate

bullClowerleaf LCP

procedure

POSITIONING OF PATIENT

INCISION

anteromedial approach a 2ndash3 cm incision is made starting at the level of the tibial plafond and extending proximally along the medial surface of the distal tibia ORposteromedial incision along the

posterior border of medialmalleolus about 4ndash5 cm in length and slightly curved can beused

PRELIMINARY REDUCTION

REDUCTION COULD BE BY MANUAL TRACTION OR BY USE OF DISTRACTOR AND REDUCTION FORCEPS PERCUTANEOUSLY

PLATE INSERTION

PLATE COULD BE INSERTED WITH HELP OF INSERTION DEVICE OR WITH HELP OF LOCKING SLEEVE UNDER SUBMUSCULAR PLANE

PRELIMINARY PLATE STABILIZATION

BY USE OF K-WIRE FOR TEMPORARY FIXATION OF PLATE

PLATE FIXATION

A MINIMUM OF 6 CORTICES ON BOTH SIDE OF FRACTURE ARE USED AND INTERFRAGMENATRY COMPRESSION SCREW WHERE NEEDED

REVIEW OF WORK

THE VARIOUS STUDY DONE TO CHECK THE EFFECTIVENESS OF MIPO TECHNIQUE FOR DISTAL END TIBIA FRACTURES ARE AS FOLLOWS

REVIEW OF WORK

STUDY NO OF FRACTURE

FIXATION OUTCOME COMPLICATION

Ronga M et al2010

19 MIPO Union 18 (223 wks range 12-24)

Nonunion1 No malunion ( ge7deg deformity or ge1 cm LLD) Deep infection3

Ahmad MA et al 2010

18 MIPO Union 15 (212 wks)

Delayed union 3 Superficial wound infarction 1 Chronic wound infection 1 Implant failure 1

Ronga M Longo UG Maffulli N Minimally invasive locked plating of distal tibia fractures is safe and effective Clin Orthop Relat Res 2010

Ahmad MA Sivaraman A Zia A Rai A Patel AD Percutaneouslocking plates for fractures of the distal tibia Our experience and a review of the literature J Trauma 2010

HasenbohehlerE et al (2007)

32 (open fracture 8)

MIPO Union 29 ( 277 wks range 24ndash60)

Nonunion 2 No malunion (ge 5deg deformity or ge 1 cm LLD) Plate bending (18deg) 1 Pseudoarthrosis 2

Hazarika S et al (2006)

20 (open fracture 8)

MIPO Union 18 ( 285 wks range 9ndash68)

Nonunion 2 Delayed wound break down 2 Wound infection 1 Implant failure 1 Secondary procedure 2

Hasenboehler E RikliD Babst R Locking compression plate with minimally invasive plate osteosynthesis in diaphyseal and distal tibial fracture a retrospective study of 32 patients Injury 2007

Hazarika S Chakravarthy J Cooper J Minimally invasive locking plate osteosynthesis for fractures of the distal tibia-results in 20 patients Injury 2006

Bahari S et al (2007)

42 (open fracture 8)

MIPO Union 42 (224 wks)

No malunionSuperficial wound infection 2 Deep infection 1 Implant failure 1

Collinge C et al(2010)

38 (open fracture 8)

MIPO Union 38 (21 wks range 9ndash48)

Malunion ( ge 5degdeformity) 1 Secondary procedure 3

Mushtaq A et al (2009)

21 (open fracture 4)

MIPO Union 21( 55 months range 3ndash13)

Delayed union 1 Non union 1 Wound infection 2 Secondary procedure 2

Bahari S LenehanB Khan H Mcelwain JP Minimally invasive percutaneous plate fixation of distal tibia fractures Acta Orthop Belg2007

Collinge C Protzman R Outcomes of minimally invasive plate osteosynthesis for metaphyseal distal tibia fractures J OrthopTrauma 2010

Mushtaq A Shahid R AsifM Maqsood M Distal tibialfracture fixation with locking compression plate (LCP) using the minimally invasive percutaneousosteosynthesis (MIPO) technique Eur J Trauma Emerg Surg 2009

Lau TW et al (2008)

48 (open fracture 9)

MIPO Union 47 ( 187 wks range 12-44 wks)

Delayed union 5 Wound infection 8 Secondary procedure1

Gupta RK et al(2010)

80 (open fracture19)

MIPO Union 77 (19 wks range 16-32)

Delayed union 7 Non union 3 Malunion (ge 5degdeformity or ge 1 cm LLD) 2 Wound infection1 Wound breakdown 2 Secondary procedure 2

Lau TW Leung F Chan CF Chow SP Wound complication of minimally invasive plate osteosynthesis in distal tibia fractures Inter Orthop 2008

Gupta RK RohillaRK Sangwan K Singh V Walia S Locking plate fixation in distal metaphysealtibial fractures series of 79 patients Inter Orthop 2010

Shreshta et al(2011)

20 MIPO Union 20 (185 wks range 14-28)

Delayed union 1 No malunion (ge 5deg deformity or ge 1 cm LLD) Superficial wound infection 2 Deep infection 1 Secondary procedure 1

Oog Jin et al 10 MIPO Union10(21 wksrange17-28)

no non-union no angular deformity gt 5deg shortening gt 10 mm no infection

Shrestha D Acharya BM Shrestha PM Minimally invasive plate osteosynthesis with locking compression plate for distal diametaphyseal tibia fracture Kathmandu Univ Med J 2011

hong et al

Fractures of the Distal Tibia Treated with PolyaxialLocking Plating

Hong Gao MD Chang-Qing Zhang MD PhD Cong-FengLuo MD PhD Zu-Bin Zhou MD and Bing-Fang Zeng

MDClin Orthop Relat Res 2009 March 467(3) 831ndash837 Total pts 32 The average healing time was 13 weeks (range 10ndash18 weeks)

for fractures using the MIPO technique and 156 weeks (range 10ndash20 weeks p = 00045) for fractures using the ORIF technique

The fracture healing time was shorter in the MIPO technique group than in the ORIF technique group which might be related to minimizing soft tissue trauma to the injured zone and preserving better blood supply around the fracture area

Contra-indication

MIPO is contraindicated in situations where the medial soft tissue is compromised such as in severe open fractures or badly contused skin

If the bone is osteoporotic or comminution is so excessive that surgery cannot restore or stabilize the joint then other methods of treatment must be sought such as external fixator

In severely shattered pilon fractures when only choice is external fixator

Advantage of mipo

minimizes risk of soft tissue damage

preserve vascular supply to bone and soft tissue

decrease periosteum damage

have better and faster callus formation

have better healing and union rate

decrease complication of infection and re-fracture

decrease the use of supplementary bone grafting

IMPLANT CHOICE

Choice of implant could be

bullMetaphysealplate (broad or narrow)

bullPrecountoureddistal tibia locking plate

bullClowerleaf LCP

procedure

POSITIONING OF PATIENT

INCISION

anteromedial approach a 2ndash3 cm incision is made starting at the level of the tibial plafond and extending proximally along the medial surface of the distal tibia ORposteromedial incision along the

posterior border of medialmalleolus about 4ndash5 cm in length and slightly curved can beused

PRELIMINARY REDUCTION

REDUCTION COULD BE BY MANUAL TRACTION OR BY USE OF DISTRACTOR AND REDUCTION FORCEPS PERCUTANEOUSLY

PLATE INSERTION

PLATE COULD BE INSERTED WITH HELP OF INSERTION DEVICE OR WITH HELP OF LOCKING SLEEVE UNDER SUBMUSCULAR PLANE

PRELIMINARY PLATE STABILIZATION

BY USE OF K-WIRE FOR TEMPORARY FIXATION OF PLATE

PLATE FIXATION

A MINIMUM OF 6 CORTICES ON BOTH SIDE OF FRACTURE ARE USED AND INTERFRAGMENATRY COMPRESSION SCREW WHERE NEEDED

REVIEW OF WORK

THE VARIOUS STUDY DONE TO CHECK THE EFFECTIVENESS OF MIPO TECHNIQUE FOR DISTAL END TIBIA FRACTURES ARE AS FOLLOWS

REVIEW OF WORK

STUDY NO OF FRACTURE

FIXATION OUTCOME COMPLICATION

Ronga M et al2010

19 MIPO Union 18 (223 wks range 12-24)

Nonunion1 No malunion ( ge7deg deformity or ge1 cm LLD) Deep infection3

Ahmad MA et al 2010

18 MIPO Union 15 (212 wks)

Delayed union 3 Superficial wound infarction 1 Chronic wound infection 1 Implant failure 1

Ronga M Longo UG Maffulli N Minimally invasive locked plating of distal tibia fractures is safe and effective Clin Orthop Relat Res 2010

Ahmad MA Sivaraman A Zia A Rai A Patel AD Percutaneouslocking plates for fractures of the distal tibia Our experience and a review of the literature J Trauma 2010

HasenbohehlerE et al (2007)

32 (open fracture 8)

MIPO Union 29 ( 277 wks range 24ndash60)

Nonunion 2 No malunion (ge 5deg deformity or ge 1 cm LLD) Plate bending (18deg) 1 Pseudoarthrosis 2

Hazarika S et al (2006)

20 (open fracture 8)

MIPO Union 18 ( 285 wks range 9ndash68)

Nonunion 2 Delayed wound break down 2 Wound infection 1 Implant failure 1 Secondary procedure 2

Hasenboehler E RikliD Babst R Locking compression plate with minimally invasive plate osteosynthesis in diaphyseal and distal tibial fracture a retrospective study of 32 patients Injury 2007

Hazarika S Chakravarthy J Cooper J Minimally invasive locking plate osteosynthesis for fractures of the distal tibia-results in 20 patients Injury 2006

Bahari S et al (2007)

42 (open fracture 8)

MIPO Union 42 (224 wks)

No malunionSuperficial wound infection 2 Deep infection 1 Implant failure 1

Collinge C et al(2010)

38 (open fracture 8)

MIPO Union 38 (21 wks range 9ndash48)

Malunion ( ge 5degdeformity) 1 Secondary procedure 3

Mushtaq A et al (2009)

21 (open fracture 4)

MIPO Union 21( 55 months range 3ndash13)

Delayed union 1 Non union 1 Wound infection 2 Secondary procedure 2

Bahari S LenehanB Khan H Mcelwain JP Minimally invasive percutaneous plate fixation of distal tibia fractures Acta Orthop Belg2007

Collinge C Protzman R Outcomes of minimally invasive plate osteosynthesis for metaphyseal distal tibia fractures J OrthopTrauma 2010

Mushtaq A Shahid R AsifM Maqsood M Distal tibialfracture fixation with locking compression plate (LCP) using the minimally invasive percutaneousosteosynthesis (MIPO) technique Eur J Trauma Emerg Surg 2009

Lau TW et al (2008)

48 (open fracture 9)

MIPO Union 47 ( 187 wks range 12-44 wks)

Delayed union 5 Wound infection 8 Secondary procedure1

Gupta RK et al(2010)

80 (open fracture19)

MIPO Union 77 (19 wks range 16-32)

Delayed union 7 Non union 3 Malunion (ge 5degdeformity or ge 1 cm LLD) 2 Wound infection1 Wound breakdown 2 Secondary procedure 2

Lau TW Leung F Chan CF Chow SP Wound complication of minimally invasive plate osteosynthesis in distal tibia fractures Inter Orthop 2008

Gupta RK RohillaRK Sangwan K Singh V Walia S Locking plate fixation in distal metaphysealtibial fractures series of 79 patients Inter Orthop 2010

Shreshta et al(2011)

20 MIPO Union 20 (185 wks range 14-28)

Delayed union 1 No malunion (ge 5deg deformity or ge 1 cm LLD) Superficial wound infection 2 Deep infection 1 Secondary procedure 1

Oog Jin et al 10 MIPO Union10(21 wksrange17-28)

no non-union no angular deformity gt 5deg shortening gt 10 mm no infection

Shrestha D Acharya BM Shrestha PM Minimally invasive plate osteosynthesis with locking compression plate for distal diametaphyseal tibia fracture Kathmandu Univ Med J 2011

hong et al

Fractures of the Distal Tibia Treated with PolyaxialLocking Plating

Hong Gao MD Chang-Qing Zhang MD PhD Cong-FengLuo MD PhD Zu-Bin Zhou MD and Bing-Fang Zeng

MDClin Orthop Relat Res 2009 March 467(3) 831ndash837 Total pts 32 The average healing time was 13 weeks (range 10ndash18 weeks)

for fractures using the MIPO technique and 156 weeks (range 10ndash20 weeks p = 00045) for fractures using the ORIF technique

The fracture healing time was shorter in the MIPO technique group than in the ORIF technique group which might be related to minimizing soft tissue trauma to the injured zone and preserving better blood supply around the fracture area

Advantage of mipo

minimizes risk of soft tissue damage

preserve vascular supply to bone and soft tissue

decrease periosteum damage

have better and faster callus formation

have better healing and union rate

decrease complication of infection and re-fracture

decrease the use of supplementary bone grafting

IMPLANT CHOICE

Choice of implant could be

bullMetaphysealplate (broad or narrow)

bullPrecountoureddistal tibia locking plate

bullClowerleaf LCP

procedure

POSITIONING OF PATIENT

INCISION

anteromedial approach a 2ndash3 cm incision is made starting at the level of the tibial plafond and extending proximally along the medial surface of the distal tibia ORposteromedial incision along the

posterior border of medialmalleolus about 4ndash5 cm in length and slightly curved can beused

PRELIMINARY REDUCTION

REDUCTION COULD BE BY MANUAL TRACTION OR BY USE OF DISTRACTOR AND REDUCTION FORCEPS PERCUTANEOUSLY

PLATE INSERTION

PLATE COULD BE INSERTED WITH HELP OF INSERTION DEVICE OR WITH HELP OF LOCKING SLEEVE UNDER SUBMUSCULAR PLANE

PRELIMINARY PLATE STABILIZATION

BY USE OF K-WIRE FOR TEMPORARY FIXATION OF PLATE

PLATE FIXATION

A MINIMUM OF 6 CORTICES ON BOTH SIDE OF FRACTURE ARE USED AND INTERFRAGMENATRY COMPRESSION SCREW WHERE NEEDED

REVIEW OF WORK

THE VARIOUS STUDY DONE TO CHECK THE EFFECTIVENESS OF MIPO TECHNIQUE FOR DISTAL END TIBIA FRACTURES ARE AS FOLLOWS

REVIEW OF WORK

STUDY NO OF FRACTURE

FIXATION OUTCOME COMPLICATION

Ronga M et al2010

19 MIPO Union 18 (223 wks range 12-24)

Nonunion1 No malunion ( ge7deg deformity or ge1 cm LLD) Deep infection3

Ahmad MA et al 2010

18 MIPO Union 15 (212 wks)

Delayed union 3 Superficial wound infarction 1 Chronic wound infection 1 Implant failure 1

Ronga M Longo UG Maffulli N Minimally invasive locked plating of distal tibia fractures is safe and effective Clin Orthop Relat Res 2010

Ahmad MA Sivaraman A Zia A Rai A Patel AD Percutaneouslocking plates for fractures of the distal tibia Our experience and a review of the literature J Trauma 2010

HasenbohehlerE et al (2007)

32 (open fracture 8)

MIPO Union 29 ( 277 wks range 24ndash60)

Nonunion 2 No malunion (ge 5deg deformity or ge 1 cm LLD) Plate bending (18deg) 1 Pseudoarthrosis 2

Hazarika S et al (2006)

20 (open fracture 8)

MIPO Union 18 ( 285 wks range 9ndash68)

Nonunion 2 Delayed wound break down 2 Wound infection 1 Implant failure 1 Secondary procedure 2

Hasenboehler E RikliD Babst R Locking compression plate with minimally invasive plate osteosynthesis in diaphyseal and distal tibial fracture a retrospective study of 32 patients Injury 2007

Hazarika S Chakravarthy J Cooper J Minimally invasive locking plate osteosynthesis for fractures of the distal tibia-results in 20 patients Injury 2006

Bahari S et al (2007)

42 (open fracture 8)

MIPO Union 42 (224 wks)

No malunionSuperficial wound infection 2 Deep infection 1 Implant failure 1

Collinge C et al(2010)

38 (open fracture 8)

MIPO Union 38 (21 wks range 9ndash48)

Malunion ( ge 5degdeformity) 1 Secondary procedure 3

Mushtaq A et al (2009)

21 (open fracture 4)

MIPO Union 21( 55 months range 3ndash13)

Delayed union 1 Non union 1 Wound infection 2 Secondary procedure 2

Bahari S LenehanB Khan H Mcelwain JP Minimally invasive percutaneous plate fixation of distal tibia fractures Acta Orthop Belg2007

Collinge C Protzman R Outcomes of minimally invasive plate osteosynthesis for metaphyseal distal tibia fractures J OrthopTrauma 2010

Mushtaq A Shahid R AsifM Maqsood M Distal tibialfracture fixation with locking compression plate (LCP) using the minimally invasive percutaneousosteosynthesis (MIPO) technique Eur J Trauma Emerg Surg 2009

Lau TW et al (2008)

48 (open fracture 9)

MIPO Union 47 ( 187 wks range 12-44 wks)

Delayed union 5 Wound infection 8 Secondary procedure1

Gupta RK et al(2010)

80 (open fracture19)

MIPO Union 77 (19 wks range 16-32)

Delayed union 7 Non union 3 Malunion (ge 5degdeformity or ge 1 cm LLD) 2 Wound infection1 Wound breakdown 2 Secondary procedure 2

Lau TW Leung F Chan CF Chow SP Wound complication of minimally invasive plate osteosynthesis in distal tibia fractures Inter Orthop 2008

Gupta RK RohillaRK Sangwan K Singh V Walia S Locking plate fixation in distal metaphysealtibial fractures series of 79 patients Inter Orthop 2010

Shreshta et al(2011)

20 MIPO Union 20 (185 wks range 14-28)

Delayed union 1 No malunion (ge 5deg deformity or ge 1 cm LLD) Superficial wound infection 2 Deep infection 1 Secondary procedure 1

Oog Jin et al 10 MIPO Union10(21 wksrange17-28)

no non-union no angular deformity gt 5deg shortening gt 10 mm no infection

Shrestha D Acharya BM Shrestha PM Minimally invasive plate osteosynthesis with locking compression plate for distal diametaphyseal tibia fracture Kathmandu Univ Med J 2011

hong et al

Fractures of the Distal Tibia Treated with PolyaxialLocking Plating

Hong Gao MD Chang-Qing Zhang MD PhD Cong-FengLuo MD PhD Zu-Bin Zhou MD and Bing-Fang Zeng

MDClin Orthop Relat Res 2009 March 467(3) 831ndash837 Total pts 32 The average healing time was 13 weeks (range 10ndash18 weeks)

for fractures using the MIPO technique and 156 weeks (range 10ndash20 weeks p = 00045) for fractures using the ORIF technique

The fracture healing time was shorter in the MIPO technique group than in the ORIF technique group which might be related to minimizing soft tissue trauma to the injured zone and preserving better blood supply around the fracture area

IMPLANT CHOICE

Choice of implant could be

bullMetaphysealplate (broad or narrow)

bullPrecountoureddistal tibia locking plate

bullClowerleaf LCP

procedure

POSITIONING OF PATIENT

INCISION

anteromedial approach a 2ndash3 cm incision is made starting at the level of the tibial plafond and extending proximally along the medial surface of the distal tibia ORposteromedial incision along the

posterior border of medialmalleolus about 4ndash5 cm in length and slightly curved can beused

PRELIMINARY REDUCTION

REDUCTION COULD BE BY MANUAL TRACTION OR BY USE OF DISTRACTOR AND REDUCTION FORCEPS PERCUTANEOUSLY

PLATE INSERTION

PLATE COULD BE INSERTED WITH HELP OF INSERTION DEVICE OR WITH HELP OF LOCKING SLEEVE UNDER SUBMUSCULAR PLANE

PRELIMINARY PLATE STABILIZATION

BY USE OF K-WIRE FOR TEMPORARY FIXATION OF PLATE

PLATE FIXATION

A MINIMUM OF 6 CORTICES ON BOTH SIDE OF FRACTURE ARE USED AND INTERFRAGMENATRY COMPRESSION SCREW WHERE NEEDED

REVIEW OF WORK

THE VARIOUS STUDY DONE TO CHECK THE EFFECTIVENESS OF MIPO TECHNIQUE FOR DISTAL END TIBIA FRACTURES ARE AS FOLLOWS

REVIEW OF WORK

STUDY NO OF FRACTURE

FIXATION OUTCOME COMPLICATION

Ronga M et al2010

19 MIPO Union 18 (223 wks range 12-24)

Nonunion1 No malunion ( ge7deg deformity or ge1 cm LLD) Deep infection3

Ahmad MA et al 2010

18 MIPO Union 15 (212 wks)

Delayed union 3 Superficial wound infarction 1 Chronic wound infection 1 Implant failure 1

Ronga M Longo UG Maffulli N Minimally invasive locked plating of distal tibia fractures is safe and effective Clin Orthop Relat Res 2010

Ahmad MA Sivaraman A Zia A Rai A Patel AD Percutaneouslocking plates for fractures of the distal tibia Our experience and a review of the literature J Trauma 2010

HasenbohehlerE et al (2007)

32 (open fracture 8)

MIPO Union 29 ( 277 wks range 24ndash60)

Nonunion 2 No malunion (ge 5deg deformity or ge 1 cm LLD) Plate bending (18deg) 1 Pseudoarthrosis 2

Hazarika S et al (2006)

20 (open fracture 8)

MIPO Union 18 ( 285 wks range 9ndash68)

Nonunion 2 Delayed wound break down 2 Wound infection 1 Implant failure 1 Secondary procedure 2

Hasenboehler E RikliD Babst R Locking compression plate with minimally invasive plate osteosynthesis in diaphyseal and distal tibial fracture a retrospective study of 32 patients Injury 2007

Hazarika S Chakravarthy J Cooper J Minimally invasive locking plate osteosynthesis for fractures of the distal tibia-results in 20 patients Injury 2006

Bahari S et al (2007)

42 (open fracture 8)

MIPO Union 42 (224 wks)

No malunionSuperficial wound infection 2 Deep infection 1 Implant failure 1

Collinge C et al(2010)

38 (open fracture 8)

MIPO Union 38 (21 wks range 9ndash48)

Malunion ( ge 5degdeformity) 1 Secondary procedure 3

Mushtaq A et al (2009)

21 (open fracture 4)

MIPO Union 21( 55 months range 3ndash13)

Delayed union 1 Non union 1 Wound infection 2 Secondary procedure 2

Bahari S LenehanB Khan H Mcelwain JP Minimally invasive percutaneous plate fixation of distal tibia fractures Acta Orthop Belg2007

Collinge C Protzman R Outcomes of minimally invasive plate osteosynthesis for metaphyseal distal tibia fractures J OrthopTrauma 2010

Mushtaq A Shahid R AsifM Maqsood M Distal tibialfracture fixation with locking compression plate (LCP) using the minimally invasive percutaneousosteosynthesis (MIPO) technique Eur J Trauma Emerg Surg 2009

Lau TW et al (2008)

48 (open fracture 9)

MIPO Union 47 ( 187 wks range 12-44 wks)

Delayed union 5 Wound infection 8 Secondary procedure1

Gupta RK et al(2010)

80 (open fracture19)

MIPO Union 77 (19 wks range 16-32)

Delayed union 7 Non union 3 Malunion (ge 5degdeformity or ge 1 cm LLD) 2 Wound infection1 Wound breakdown 2 Secondary procedure 2

Lau TW Leung F Chan CF Chow SP Wound complication of minimally invasive plate osteosynthesis in distal tibia fractures Inter Orthop 2008

Gupta RK RohillaRK Sangwan K Singh V Walia S Locking plate fixation in distal metaphysealtibial fractures series of 79 patients Inter Orthop 2010

Shreshta et al(2011)

20 MIPO Union 20 (185 wks range 14-28)

Delayed union 1 No malunion (ge 5deg deformity or ge 1 cm LLD) Superficial wound infection 2 Deep infection 1 Secondary procedure 1

Oog Jin et al 10 MIPO Union10(21 wksrange17-28)

no non-union no angular deformity gt 5deg shortening gt 10 mm no infection

Shrestha D Acharya BM Shrestha PM Minimally invasive plate osteosynthesis with locking compression plate for distal diametaphyseal tibia fracture Kathmandu Univ Med J 2011

hong et al

Fractures of the Distal Tibia Treated with PolyaxialLocking Plating

Hong Gao MD Chang-Qing Zhang MD PhD Cong-FengLuo MD PhD Zu-Bin Zhou MD and Bing-Fang Zeng

MDClin Orthop Relat Res 2009 March 467(3) 831ndash837 Total pts 32 The average healing time was 13 weeks (range 10ndash18 weeks)

for fractures using the MIPO technique and 156 weeks (range 10ndash20 weeks p = 00045) for fractures using the ORIF technique

The fracture healing time was shorter in the MIPO technique group than in the ORIF technique group which might be related to minimizing soft tissue trauma to the injured zone and preserving better blood supply around the fracture area

procedure

POSITIONING OF PATIENT

INCISION

anteromedial approach a 2ndash3 cm incision is made starting at the level of the tibial plafond and extending proximally along the medial surface of the distal tibia ORposteromedial incision along the

posterior border of medialmalleolus about 4ndash5 cm in length and slightly curved can beused

PRELIMINARY REDUCTION

REDUCTION COULD BE BY MANUAL TRACTION OR BY USE OF DISTRACTOR AND REDUCTION FORCEPS PERCUTANEOUSLY

PLATE INSERTION

PLATE COULD BE INSERTED WITH HELP OF INSERTION DEVICE OR WITH HELP OF LOCKING SLEEVE UNDER SUBMUSCULAR PLANE

PRELIMINARY PLATE STABILIZATION

BY USE OF K-WIRE FOR TEMPORARY FIXATION OF PLATE

PLATE FIXATION

A MINIMUM OF 6 CORTICES ON BOTH SIDE OF FRACTURE ARE USED AND INTERFRAGMENATRY COMPRESSION SCREW WHERE NEEDED

REVIEW OF WORK

THE VARIOUS STUDY DONE TO CHECK THE EFFECTIVENESS OF MIPO TECHNIQUE FOR DISTAL END TIBIA FRACTURES ARE AS FOLLOWS

REVIEW OF WORK

STUDY NO OF FRACTURE

FIXATION OUTCOME COMPLICATION

Ronga M et al2010

19 MIPO Union 18 (223 wks range 12-24)

Nonunion1 No malunion ( ge7deg deformity or ge1 cm LLD) Deep infection3

Ahmad MA et al 2010

18 MIPO Union 15 (212 wks)

Delayed union 3 Superficial wound infarction 1 Chronic wound infection 1 Implant failure 1

Ronga M Longo UG Maffulli N Minimally invasive locked plating of distal tibia fractures is safe and effective Clin Orthop Relat Res 2010

Ahmad MA Sivaraman A Zia A Rai A Patel AD Percutaneouslocking plates for fractures of the distal tibia Our experience and a review of the literature J Trauma 2010

HasenbohehlerE et al (2007)

32 (open fracture 8)

MIPO Union 29 ( 277 wks range 24ndash60)

Nonunion 2 No malunion (ge 5deg deformity or ge 1 cm LLD) Plate bending (18deg) 1 Pseudoarthrosis 2

Hazarika S et al (2006)

20 (open fracture 8)

MIPO Union 18 ( 285 wks range 9ndash68)

Nonunion 2 Delayed wound break down 2 Wound infection 1 Implant failure 1 Secondary procedure 2

Hasenboehler E RikliD Babst R Locking compression plate with minimally invasive plate osteosynthesis in diaphyseal and distal tibial fracture a retrospective study of 32 patients Injury 2007

Hazarika S Chakravarthy J Cooper J Minimally invasive locking plate osteosynthesis for fractures of the distal tibia-results in 20 patients Injury 2006

Bahari S et al (2007)

42 (open fracture 8)

MIPO Union 42 (224 wks)

No malunionSuperficial wound infection 2 Deep infection 1 Implant failure 1

Collinge C et al(2010)

38 (open fracture 8)

MIPO Union 38 (21 wks range 9ndash48)

Malunion ( ge 5degdeformity) 1 Secondary procedure 3

Mushtaq A et al (2009)

21 (open fracture 4)

MIPO Union 21( 55 months range 3ndash13)

Delayed union 1 Non union 1 Wound infection 2 Secondary procedure 2

Bahari S LenehanB Khan H Mcelwain JP Minimally invasive percutaneous plate fixation of distal tibia fractures Acta Orthop Belg2007

Collinge C Protzman R Outcomes of minimally invasive plate osteosynthesis for metaphyseal distal tibia fractures J OrthopTrauma 2010

Mushtaq A Shahid R AsifM Maqsood M Distal tibialfracture fixation with locking compression plate (LCP) using the minimally invasive percutaneousosteosynthesis (MIPO) technique Eur J Trauma Emerg Surg 2009

Lau TW et al (2008)

48 (open fracture 9)

MIPO Union 47 ( 187 wks range 12-44 wks)

Delayed union 5 Wound infection 8 Secondary procedure1

Gupta RK et al(2010)

80 (open fracture19)

MIPO Union 77 (19 wks range 16-32)

Delayed union 7 Non union 3 Malunion (ge 5degdeformity or ge 1 cm LLD) 2 Wound infection1 Wound breakdown 2 Secondary procedure 2

Lau TW Leung F Chan CF Chow SP Wound complication of minimally invasive plate osteosynthesis in distal tibia fractures Inter Orthop 2008

Gupta RK RohillaRK Sangwan K Singh V Walia S Locking plate fixation in distal metaphysealtibial fractures series of 79 patients Inter Orthop 2010

Shreshta et al(2011)

20 MIPO Union 20 (185 wks range 14-28)

Delayed union 1 No malunion (ge 5deg deformity or ge 1 cm LLD) Superficial wound infection 2 Deep infection 1 Secondary procedure 1

Oog Jin et al 10 MIPO Union10(21 wksrange17-28)

no non-union no angular deformity gt 5deg shortening gt 10 mm no infection

Shrestha D Acharya BM Shrestha PM Minimally invasive plate osteosynthesis with locking compression plate for distal diametaphyseal tibia fracture Kathmandu Univ Med J 2011

hong et al

Fractures of the Distal Tibia Treated with PolyaxialLocking Plating

Hong Gao MD Chang-Qing Zhang MD PhD Cong-FengLuo MD PhD Zu-Bin Zhou MD and Bing-Fang Zeng

MDClin Orthop Relat Res 2009 March 467(3) 831ndash837 Total pts 32 The average healing time was 13 weeks (range 10ndash18 weeks)

for fractures using the MIPO technique and 156 weeks (range 10ndash20 weeks p = 00045) for fractures using the ORIF technique

The fracture healing time was shorter in the MIPO technique group than in the ORIF technique group which might be related to minimizing soft tissue trauma to the injured zone and preserving better blood supply around the fracture area

INCISION

anteromedial approach a 2ndash3 cm incision is made starting at the level of the tibial plafond and extending proximally along the medial surface of the distal tibia ORposteromedial incision along the

posterior border of medialmalleolus about 4ndash5 cm in length and slightly curved can beused

PRELIMINARY REDUCTION

REDUCTION COULD BE BY MANUAL TRACTION OR BY USE OF DISTRACTOR AND REDUCTION FORCEPS PERCUTANEOUSLY

PLATE INSERTION

PLATE COULD BE INSERTED WITH HELP OF INSERTION DEVICE OR WITH HELP OF LOCKING SLEEVE UNDER SUBMUSCULAR PLANE

PRELIMINARY PLATE STABILIZATION

BY USE OF K-WIRE FOR TEMPORARY FIXATION OF PLATE

PLATE FIXATION

A MINIMUM OF 6 CORTICES ON BOTH SIDE OF FRACTURE ARE USED AND INTERFRAGMENATRY COMPRESSION SCREW WHERE NEEDED

REVIEW OF WORK

THE VARIOUS STUDY DONE TO CHECK THE EFFECTIVENESS OF MIPO TECHNIQUE FOR DISTAL END TIBIA FRACTURES ARE AS FOLLOWS

REVIEW OF WORK

STUDY NO OF FRACTURE

FIXATION OUTCOME COMPLICATION

Ronga M et al2010

19 MIPO Union 18 (223 wks range 12-24)

Nonunion1 No malunion ( ge7deg deformity or ge1 cm LLD) Deep infection3

Ahmad MA et al 2010

18 MIPO Union 15 (212 wks)

Delayed union 3 Superficial wound infarction 1 Chronic wound infection 1 Implant failure 1

Ronga M Longo UG Maffulli N Minimally invasive locked plating of distal tibia fractures is safe and effective Clin Orthop Relat Res 2010

Ahmad MA Sivaraman A Zia A Rai A Patel AD Percutaneouslocking plates for fractures of the distal tibia Our experience and a review of the literature J Trauma 2010

HasenbohehlerE et al (2007)

32 (open fracture 8)

MIPO Union 29 ( 277 wks range 24ndash60)

Nonunion 2 No malunion (ge 5deg deformity or ge 1 cm LLD) Plate bending (18deg) 1 Pseudoarthrosis 2

Hazarika S et al (2006)

20 (open fracture 8)

MIPO Union 18 ( 285 wks range 9ndash68)

Nonunion 2 Delayed wound break down 2 Wound infection 1 Implant failure 1 Secondary procedure 2

Hasenboehler E RikliD Babst R Locking compression plate with minimally invasive plate osteosynthesis in diaphyseal and distal tibial fracture a retrospective study of 32 patients Injury 2007

Hazarika S Chakravarthy J Cooper J Minimally invasive locking plate osteosynthesis for fractures of the distal tibia-results in 20 patients Injury 2006

Bahari S et al (2007)

42 (open fracture 8)

MIPO Union 42 (224 wks)

No malunionSuperficial wound infection 2 Deep infection 1 Implant failure 1

Collinge C et al(2010)

38 (open fracture 8)

MIPO Union 38 (21 wks range 9ndash48)

Malunion ( ge 5degdeformity) 1 Secondary procedure 3

Mushtaq A et al (2009)

21 (open fracture 4)

MIPO Union 21( 55 months range 3ndash13)

Delayed union 1 Non union 1 Wound infection 2 Secondary procedure 2

Bahari S LenehanB Khan H Mcelwain JP Minimally invasive percutaneous plate fixation of distal tibia fractures Acta Orthop Belg2007

Collinge C Protzman R Outcomes of minimally invasive plate osteosynthesis for metaphyseal distal tibia fractures J OrthopTrauma 2010

Mushtaq A Shahid R AsifM Maqsood M Distal tibialfracture fixation with locking compression plate (LCP) using the minimally invasive percutaneousosteosynthesis (MIPO) technique Eur J Trauma Emerg Surg 2009

Lau TW et al (2008)

48 (open fracture 9)

MIPO Union 47 ( 187 wks range 12-44 wks)

Delayed union 5 Wound infection 8 Secondary procedure1

Gupta RK et al(2010)

80 (open fracture19)

MIPO Union 77 (19 wks range 16-32)

Delayed union 7 Non union 3 Malunion (ge 5degdeformity or ge 1 cm LLD) 2 Wound infection1 Wound breakdown 2 Secondary procedure 2

Lau TW Leung F Chan CF Chow SP Wound complication of minimally invasive plate osteosynthesis in distal tibia fractures Inter Orthop 2008

Gupta RK RohillaRK Sangwan K Singh V Walia S Locking plate fixation in distal metaphysealtibial fractures series of 79 patients Inter Orthop 2010

Shreshta et al(2011)

20 MIPO Union 20 (185 wks range 14-28)

Delayed union 1 No malunion (ge 5deg deformity or ge 1 cm LLD) Superficial wound infection 2 Deep infection 1 Secondary procedure 1

Oog Jin et al 10 MIPO Union10(21 wksrange17-28)

no non-union no angular deformity gt 5deg shortening gt 10 mm no infection

Shrestha D Acharya BM Shrestha PM Minimally invasive plate osteosynthesis with locking compression plate for distal diametaphyseal tibia fracture Kathmandu Univ Med J 2011

hong et al

Fractures of the Distal Tibia Treated with PolyaxialLocking Plating

Hong Gao MD Chang-Qing Zhang MD PhD Cong-FengLuo MD PhD Zu-Bin Zhou MD and Bing-Fang Zeng

MDClin Orthop Relat Res 2009 March 467(3) 831ndash837 Total pts 32 The average healing time was 13 weeks (range 10ndash18 weeks)

for fractures using the MIPO technique and 156 weeks (range 10ndash20 weeks p = 00045) for fractures using the ORIF technique

The fracture healing time was shorter in the MIPO technique group than in the ORIF technique group which might be related to minimizing soft tissue trauma to the injured zone and preserving better blood supply around the fracture area

PRELIMINARY REDUCTION

REDUCTION COULD BE BY MANUAL TRACTION OR BY USE OF DISTRACTOR AND REDUCTION FORCEPS PERCUTANEOUSLY

PLATE INSERTION

PLATE COULD BE INSERTED WITH HELP OF INSERTION DEVICE OR WITH HELP OF LOCKING SLEEVE UNDER SUBMUSCULAR PLANE

PRELIMINARY PLATE STABILIZATION

BY USE OF K-WIRE FOR TEMPORARY FIXATION OF PLATE

PLATE FIXATION

A MINIMUM OF 6 CORTICES ON BOTH SIDE OF FRACTURE ARE USED AND INTERFRAGMENATRY COMPRESSION SCREW WHERE NEEDED

REVIEW OF WORK

THE VARIOUS STUDY DONE TO CHECK THE EFFECTIVENESS OF MIPO TECHNIQUE FOR DISTAL END TIBIA FRACTURES ARE AS FOLLOWS

REVIEW OF WORK

STUDY NO OF FRACTURE

FIXATION OUTCOME COMPLICATION

Ronga M et al2010

19 MIPO Union 18 (223 wks range 12-24)

Nonunion1 No malunion ( ge7deg deformity or ge1 cm LLD) Deep infection3

Ahmad MA et al 2010

18 MIPO Union 15 (212 wks)

Delayed union 3 Superficial wound infarction 1 Chronic wound infection 1 Implant failure 1

Ronga M Longo UG Maffulli N Minimally invasive locked plating of distal tibia fractures is safe and effective Clin Orthop Relat Res 2010

Ahmad MA Sivaraman A Zia A Rai A Patel AD Percutaneouslocking plates for fractures of the distal tibia Our experience and a review of the literature J Trauma 2010

HasenbohehlerE et al (2007)

32 (open fracture 8)

MIPO Union 29 ( 277 wks range 24ndash60)

Nonunion 2 No malunion (ge 5deg deformity or ge 1 cm LLD) Plate bending (18deg) 1 Pseudoarthrosis 2

Hazarika S et al (2006)

20 (open fracture 8)

MIPO Union 18 ( 285 wks range 9ndash68)

Nonunion 2 Delayed wound break down 2 Wound infection 1 Implant failure 1 Secondary procedure 2

Hasenboehler E RikliD Babst R Locking compression plate with minimally invasive plate osteosynthesis in diaphyseal and distal tibial fracture a retrospective study of 32 patients Injury 2007

Hazarika S Chakravarthy J Cooper J Minimally invasive locking plate osteosynthesis for fractures of the distal tibia-results in 20 patients Injury 2006

Bahari S et al (2007)

42 (open fracture 8)

MIPO Union 42 (224 wks)

No malunionSuperficial wound infection 2 Deep infection 1 Implant failure 1

Collinge C et al(2010)

38 (open fracture 8)

MIPO Union 38 (21 wks range 9ndash48)

Malunion ( ge 5degdeformity) 1 Secondary procedure 3

Mushtaq A et al (2009)

21 (open fracture 4)

MIPO Union 21( 55 months range 3ndash13)

Delayed union 1 Non union 1 Wound infection 2 Secondary procedure 2

Bahari S LenehanB Khan H Mcelwain JP Minimally invasive percutaneous plate fixation of distal tibia fractures Acta Orthop Belg2007

Collinge C Protzman R Outcomes of minimally invasive plate osteosynthesis for metaphyseal distal tibia fractures J OrthopTrauma 2010

Mushtaq A Shahid R AsifM Maqsood M Distal tibialfracture fixation with locking compression plate (LCP) using the minimally invasive percutaneousosteosynthesis (MIPO) technique Eur J Trauma Emerg Surg 2009

Lau TW et al (2008)

48 (open fracture 9)

MIPO Union 47 ( 187 wks range 12-44 wks)

Delayed union 5 Wound infection 8 Secondary procedure1

Gupta RK et al(2010)

80 (open fracture19)

MIPO Union 77 (19 wks range 16-32)

Delayed union 7 Non union 3 Malunion (ge 5degdeformity or ge 1 cm LLD) 2 Wound infection1 Wound breakdown 2 Secondary procedure 2

Lau TW Leung F Chan CF Chow SP Wound complication of minimally invasive plate osteosynthesis in distal tibia fractures Inter Orthop 2008

Gupta RK RohillaRK Sangwan K Singh V Walia S Locking plate fixation in distal metaphysealtibial fractures series of 79 patients Inter Orthop 2010

Shreshta et al(2011)

20 MIPO Union 20 (185 wks range 14-28)

Delayed union 1 No malunion (ge 5deg deformity or ge 1 cm LLD) Superficial wound infection 2 Deep infection 1 Secondary procedure 1

Oog Jin et al 10 MIPO Union10(21 wksrange17-28)

no non-union no angular deformity gt 5deg shortening gt 10 mm no infection

Shrestha D Acharya BM Shrestha PM Minimally invasive plate osteosynthesis with locking compression plate for distal diametaphyseal tibia fracture Kathmandu Univ Med J 2011

hong et al

Fractures of the Distal Tibia Treated with PolyaxialLocking Plating

Hong Gao MD Chang-Qing Zhang MD PhD Cong-FengLuo MD PhD Zu-Bin Zhou MD and Bing-Fang Zeng

MDClin Orthop Relat Res 2009 March 467(3) 831ndash837 Total pts 32 The average healing time was 13 weeks (range 10ndash18 weeks)

for fractures using the MIPO technique and 156 weeks (range 10ndash20 weeks p = 00045) for fractures using the ORIF technique

The fracture healing time was shorter in the MIPO technique group than in the ORIF technique group which might be related to minimizing soft tissue trauma to the injured zone and preserving better blood supply around the fracture area

PRELIMINARY PLATE STABILIZATION

BY USE OF K-WIRE FOR TEMPORARY FIXATION OF PLATE

PLATE FIXATION

A MINIMUM OF 6 CORTICES ON BOTH SIDE OF FRACTURE ARE USED AND INTERFRAGMENATRY COMPRESSION SCREW WHERE NEEDED

REVIEW OF WORK

THE VARIOUS STUDY DONE TO CHECK THE EFFECTIVENESS OF MIPO TECHNIQUE FOR DISTAL END TIBIA FRACTURES ARE AS FOLLOWS

REVIEW OF WORK

STUDY NO OF FRACTURE

FIXATION OUTCOME COMPLICATION

Ronga M et al2010

19 MIPO Union 18 (223 wks range 12-24)

Nonunion1 No malunion ( ge7deg deformity or ge1 cm LLD) Deep infection3

Ahmad MA et al 2010

18 MIPO Union 15 (212 wks)

Delayed union 3 Superficial wound infarction 1 Chronic wound infection 1 Implant failure 1

Ronga M Longo UG Maffulli N Minimally invasive locked plating of distal tibia fractures is safe and effective Clin Orthop Relat Res 2010

Ahmad MA Sivaraman A Zia A Rai A Patel AD Percutaneouslocking plates for fractures of the distal tibia Our experience and a review of the literature J Trauma 2010

HasenbohehlerE et al (2007)

32 (open fracture 8)

MIPO Union 29 ( 277 wks range 24ndash60)

Nonunion 2 No malunion (ge 5deg deformity or ge 1 cm LLD) Plate bending (18deg) 1 Pseudoarthrosis 2

Hazarika S et al (2006)

20 (open fracture 8)

MIPO Union 18 ( 285 wks range 9ndash68)

Nonunion 2 Delayed wound break down 2 Wound infection 1 Implant failure 1 Secondary procedure 2

Hasenboehler E RikliD Babst R Locking compression plate with minimally invasive plate osteosynthesis in diaphyseal and distal tibial fracture a retrospective study of 32 patients Injury 2007

Hazarika S Chakravarthy J Cooper J Minimally invasive locking plate osteosynthesis for fractures of the distal tibia-results in 20 patients Injury 2006

Bahari S et al (2007)

42 (open fracture 8)

MIPO Union 42 (224 wks)

No malunionSuperficial wound infection 2 Deep infection 1 Implant failure 1

Collinge C et al(2010)

38 (open fracture 8)

MIPO Union 38 (21 wks range 9ndash48)

Malunion ( ge 5degdeformity) 1 Secondary procedure 3

Mushtaq A et al (2009)

21 (open fracture 4)

MIPO Union 21( 55 months range 3ndash13)

Delayed union 1 Non union 1 Wound infection 2 Secondary procedure 2

Bahari S LenehanB Khan H Mcelwain JP Minimally invasive percutaneous plate fixation of distal tibia fractures Acta Orthop Belg2007

Collinge C Protzman R Outcomes of minimally invasive plate osteosynthesis for metaphyseal distal tibia fractures J OrthopTrauma 2010

Mushtaq A Shahid R AsifM Maqsood M Distal tibialfracture fixation with locking compression plate (LCP) using the minimally invasive percutaneousosteosynthesis (MIPO) technique Eur J Trauma Emerg Surg 2009

Lau TW et al (2008)

48 (open fracture 9)

MIPO Union 47 ( 187 wks range 12-44 wks)

Delayed union 5 Wound infection 8 Secondary procedure1

Gupta RK et al(2010)

80 (open fracture19)

MIPO Union 77 (19 wks range 16-32)

Delayed union 7 Non union 3 Malunion (ge 5degdeformity or ge 1 cm LLD) 2 Wound infection1 Wound breakdown 2 Secondary procedure 2

Lau TW Leung F Chan CF Chow SP Wound complication of minimally invasive plate osteosynthesis in distal tibia fractures Inter Orthop 2008

Gupta RK RohillaRK Sangwan K Singh V Walia S Locking plate fixation in distal metaphysealtibial fractures series of 79 patients Inter Orthop 2010

Shreshta et al(2011)

20 MIPO Union 20 (185 wks range 14-28)

Delayed union 1 No malunion (ge 5deg deformity or ge 1 cm LLD) Superficial wound infection 2 Deep infection 1 Secondary procedure 1

Oog Jin et al 10 MIPO Union10(21 wksrange17-28)

no non-union no angular deformity gt 5deg shortening gt 10 mm no infection

Shrestha D Acharya BM Shrestha PM Minimally invasive plate osteosynthesis with locking compression plate for distal diametaphyseal tibia fracture Kathmandu Univ Med J 2011

hong et al

Fractures of the Distal Tibia Treated with PolyaxialLocking Plating

Hong Gao MD Chang-Qing Zhang MD PhD Cong-FengLuo MD PhD Zu-Bin Zhou MD and Bing-Fang Zeng

MDClin Orthop Relat Res 2009 March 467(3) 831ndash837 Total pts 32 The average healing time was 13 weeks (range 10ndash18 weeks)

for fractures using the MIPO technique and 156 weeks (range 10ndash20 weeks p = 00045) for fractures using the ORIF technique

The fracture healing time was shorter in the MIPO technique group than in the ORIF technique group which might be related to minimizing soft tissue trauma to the injured zone and preserving better blood supply around the fracture area

REVIEW OF WORK

THE VARIOUS STUDY DONE TO CHECK THE EFFECTIVENESS OF MIPO TECHNIQUE FOR DISTAL END TIBIA FRACTURES ARE AS FOLLOWS

REVIEW OF WORK

STUDY NO OF FRACTURE

FIXATION OUTCOME COMPLICATION

Ronga M et al2010

19 MIPO Union 18 (223 wks range 12-24)

Nonunion1 No malunion ( ge7deg deformity or ge1 cm LLD) Deep infection3

Ahmad MA et al 2010

18 MIPO Union 15 (212 wks)

Delayed union 3 Superficial wound infarction 1 Chronic wound infection 1 Implant failure 1

Ronga M Longo UG Maffulli N Minimally invasive locked plating of distal tibia fractures is safe and effective Clin Orthop Relat Res 2010

Ahmad MA Sivaraman A Zia A Rai A Patel AD Percutaneouslocking plates for fractures of the distal tibia Our experience and a review of the literature J Trauma 2010

HasenbohehlerE et al (2007)

32 (open fracture 8)

MIPO Union 29 ( 277 wks range 24ndash60)

Nonunion 2 No malunion (ge 5deg deformity or ge 1 cm LLD) Plate bending (18deg) 1 Pseudoarthrosis 2

Hazarika S et al (2006)

20 (open fracture 8)

MIPO Union 18 ( 285 wks range 9ndash68)

Nonunion 2 Delayed wound break down 2 Wound infection 1 Implant failure 1 Secondary procedure 2

Hasenboehler E RikliD Babst R Locking compression plate with minimally invasive plate osteosynthesis in diaphyseal and distal tibial fracture a retrospective study of 32 patients Injury 2007

Hazarika S Chakravarthy J Cooper J Minimally invasive locking plate osteosynthesis for fractures of the distal tibia-results in 20 patients Injury 2006

Bahari S et al (2007)

42 (open fracture 8)

MIPO Union 42 (224 wks)

No malunionSuperficial wound infection 2 Deep infection 1 Implant failure 1

Collinge C et al(2010)

38 (open fracture 8)

MIPO Union 38 (21 wks range 9ndash48)

Malunion ( ge 5degdeformity) 1 Secondary procedure 3

Mushtaq A et al (2009)

21 (open fracture 4)

MIPO Union 21( 55 months range 3ndash13)

Delayed union 1 Non union 1 Wound infection 2 Secondary procedure 2

Bahari S LenehanB Khan H Mcelwain JP Minimally invasive percutaneous plate fixation of distal tibia fractures Acta Orthop Belg2007

Collinge C Protzman R Outcomes of minimally invasive plate osteosynthesis for metaphyseal distal tibia fractures J OrthopTrauma 2010

Mushtaq A Shahid R AsifM Maqsood M Distal tibialfracture fixation with locking compression plate (LCP) using the minimally invasive percutaneousosteosynthesis (MIPO) technique Eur J Trauma Emerg Surg 2009

Lau TW et al (2008)

48 (open fracture 9)

MIPO Union 47 ( 187 wks range 12-44 wks)

Delayed union 5 Wound infection 8 Secondary procedure1

Gupta RK et al(2010)

80 (open fracture19)

MIPO Union 77 (19 wks range 16-32)

Delayed union 7 Non union 3 Malunion (ge 5degdeformity or ge 1 cm LLD) 2 Wound infection1 Wound breakdown 2 Secondary procedure 2

Lau TW Leung F Chan CF Chow SP Wound complication of minimally invasive plate osteosynthesis in distal tibia fractures Inter Orthop 2008

Gupta RK RohillaRK Sangwan K Singh V Walia S Locking plate fixation in distal metaphysealtibial fractures series of 79 patients Inter Orthop 2010

Shreshta et al(2011)

20 MIPO Union 20 (185 wks range 14-28)

Delayed union 1 No malunion (ge 5deg deformity or ge 1 cm LLD) Superficial wound infection 2 Deep infection 1 Secondary procedure 1

Oog Jin et al 10 MIPO Union10(21 wksrange17-28)

no non-union no angular deformity gt 5deg shortening gt 10 mm no infection

Shrestha D Acharya BM Shrestha PM Minimally invasive plate osteosynthesis with locking compression plate for distal diametaphyseal tibia fracture Kathmandu Univ Med J 2011

hong et al

Fractures of the Distal Tibia Treated with PolyaxialLocking Plating

Hong Gao MD Chang-Qing Zhang MD PhD Cong-FengLuo MD PhD Zu-Bin Zhou MD and Bing-Fang Zeng

MDClin Orthop Relat Res 2009 March 467(3) 831ndash837 Total pts 32 The average healing time was 13 weeks (range 10ndash18 weeks)

for fractures using the MIPO technique and 156 weeks (range 10ndash20 weeks p = 00045) for fractures using the ORIF technique

The fracture healing time was shorter in the MIPO technique group than in the ORIF technique group which might be related to minimizing soft tissue trauma to the injured zone and preserving better blood supply around the fracture area

REVIEW OF WORK

STUDY NO OF FRACTURE

FIXATION OUTCOME COMPLICATION

Ronga M et al2010

19 MIPO Union 18 (223 wks range 12-24)

Nonunion1 No malunion ( ge7deg deformity or ge1 cm LLD) Deep infection3

Ahmad MA et al 2010

18 MIPO Union 15 (212 wks)

Delayed union 3 Superficial wound infarction 1 Chronic wound infection 1 Implant failure 1

Ronga M Longo UG Maffulli N Minimally invasive locked plating of distal tibia fractures is safe and effective Clin Orthop Relat Res 2010

Ahmad MA Sivaraman A Zia A Rai A Patel AD Percutaneouslocking plates for fractures of the distal tibia Our experience and a review of the literature J Trauma 2010

HasenbohehlerE et al (2007)

32 (open fracture 8)

MIPO Union 29 ( 277 wks range 24ndash60)

Nonunion 2 No malunion (ge 5deg deformity or ge 1 cm LLD) Plate bending (18deg) 1 Pseudoarthrosis 2

Hazarika S et al (2006)

20 (open fracture 8)

MIPO Union 18 ( 285 wks range 9ndash68)

Nonunion 2 Delayed wound break down 2 Wound infection 1 Implant failure 1 Secondary procedure 2

Hasenboehler E RikliD Babst R Locking compression plate with minimally invasive plate osteosynthesis in diaphyseal and distal tibial fracture a retrospective study of 32 patients Injury 2007

Hazarika S Chakravarthy J Cooper J Minimally invasive locking plate osteosynthesis for fractures of the distal tibia-results in 20 patients Injury 2006

Bahari S et al (2007)

42 (open fracture 8)

MIPO Union 42 (224 wks)

No malunionSuperficial wound infection 2 Deep infection 1 Implant failure 1

Collinge C et al(2010)

38 (open fracture 8)

MIPO Union 38 (21 wks range 9ndash48)

Malunion ( ge 5degdeformity) 1 Secondary procedure 3

Mushtaq A et al (2009)

21 (open fracture 4)

MIPO Union 21( 55 months range 3ndash13)

Delayed union 1 Non union 1 Wound infection 2 Secondary procedure 2

Bahari S LenehanB Khan H Mcelwain JP Minimally invasive percutaneous plate fixation of distal tibia fractures Acta Orthop Belg2007

Collinge C Protzman R Outcomes of minimally invasive plate osteosynthesis for metaphyseal distal tibia fractures J OrthopTrauma 2010

Mushtaq A Shahid R AsifM Maqsood M Distal tibialfracture fixation with locking compression plate (LCP) using the minimally invasive percutaneousosteosynthesis (MIPO) technique Eur J Trauma Emerg Surg 2009

Lau TW et al (2008)

48 (open fracture 9)

MIPO Union 47 ( 187 wks range 12-44 wks)

Delayed union 5 Wound infection 8 Secondary procedure1

Gupta RK et al(2010)

80 (open fracture19)

MIPO Union 77 (19 wks range 16-32)

Delayed union 7 Non union 3 Malunion (ge 5degdeformity or ge 1 cm LLD) 2 Wound infection1 Wound breakdown 2 Secondary procedure 2

Lau TW Leung F Chan CF Chow SP Wound complication of minimally invasive plate osteosynthesis in distal tibia fractures Inter Orthop 2008

Gupta RK RohillaRK Sangwan K Singh V Walia S Locking plate fixation in distal metaphysealtibial fractures series of 79 patients Inter Orthop 2010

Shreshta et al(2011)

20 MIPO Union 20 (185 wks range 14-28)

Delayed union 1 No malunion (ge 5deg deformity or ge 1 cm LLD) Superficial wound infection 2 Deep infection 1 Secondary procedure 1

Oog Jin et al 10 MIPO Union10(21 wksrange17-28)

no non-union no angular deformity gt 5deg shortening gt 10 mm no infection

Shrestha D Acharya BM Shrestha PM Minimally invasive plate osteosynthesis with locking compression plate for distal diametaphyseal tibia fracture Kathmandu Univ Med J 2011

hong et al

Fractures of the Distal Tibia Treated with PolyaxialLocking Plating

Hong Gao MD Chang-Qing Zhang MD PhD Cong-FengLuo MD PhD Zu-Bin Zhou MD and Bing-Fang Zeng

MDClin Orthop Relat Res 2009 March 467(3) 831ndash837 Total pts 32 The average healing time was 13 weeks (range 10ndash18 weeks)

for fractures using the MIPO technique and 156 weeks (range 10ndash20 weeks p = 00045) for fractures using the ORIF technique

The fracture healing time was shorter in the MIPO technique group than in the ORIF technique group which might be related to minimizing soft tissue trauma to the injured zone and preserving better blood supply around the fracture area

HasenbohehlerE et al (2007)

32 (open fracture 8)

MIPO Union 29 ( 277 wks range 24ndash60)

Nonunion 2 No malunion (ge 5deg deformity or ge 1 cm LLD) Plate bending (18deg) 1 Pseudoarthrosis 2

Hazarika S et al (2006)

20 (open fracture 8)

MIPO Union 18 ( 285 wks range 9ndash68)

Nonunion 2 Delayed wound break down 2 Wound infection 1 Implant failure 1 Secondary procedure 2

Hasenboehler E RikliD Babst R Locking compression plate with minimally invasive plate osteosynthesis in diaphyseal and distal tibial fracture a retrospective study of 32 patients Injury 2007

Hazarika S Chakravarthy J Cooper J Minimally invasive locking plate osteosynthesis for fractures of the distal tibia-results in 20 patients Injury 2006

Bahari S et al (2007)

42 (open fracture 8)

MIPO Union 42 (224 wks)

No malunionSuperficial wound infection 2 Deep infection 1 Implant failure 1

Collinge C et al(2010)

38 (open fracture 8)

MIPO Union 38 (21 wks range 9ndash48)

Malunion ( ge 5degdeformity) 1 Secondary procedure 3

Mushtaq A et al (2009)

21 (open fracture 4)

MIPO Union 21( 55 months range 3ndash13)

Delayed union 1 Non union 1 Wound infection 2 Secondary procedure 2

Bahari S LenehanB Khan H Mcelwain JP Minimally invasive percutaneous plate fixation of distal tibia fractures Acta Orthop Belg2007

Collinge C Protzman R Outcomes of minimally invasive plate osteosynthesis for metaphyseal distal tibia fractures J OrthopTrauma 2010

Mushtaq A Shahid R AsifM Maqsood M Distal tibialfracture fixation with locking compression plate (LCP) using the minimally invasive percutaneousosteosynthesis (MIPO) technique Eur J Trauma Emerg Surg 2009

Lau TW et al (2008)

48 (open fracture 9)

MIPO Union 47 ( 187 wks range 12-44 wks)

Delayed union 5 Wound infection 8 Secondary procedure1

Gupta RK et al(2010)

80 (open fracture19)

MIPO Union 77 (19 wks range 16-32)

Delayed union 7 Non union 3 Malunion (ge 5degdeformity or ge 1 cm LLD) 2 Wound infection1 Wound breakdown 2 Secondary procedure 2

Lau TW Leung F Chan CF Chow SP Wound complication of minimally invasive plate osteosynthesis in distal tibia fractures Inter Orthop 2008

Gupta RK RohillaRK Sangwan K Singh V Walia S Locking plate fixation in distal metaphysealtibial fractures series of 79 patients Inter Orthop 2010

Shreshta et al(2011)

20 MIPO Union 20 (185 wks range 14-28)

Delayed union 1 No malunion (ge 5deg deformity or ge 1 cm LLD) Superficial wound infection 2 Deep infection 1 Secondary procedure 1

Oog Jin et al 10 MIPO Union10(21 wksrange17-28)

no non-union no angular deformity gt 5deg shortening gt 10 mm no infection

Shrestha D Acharya BM Shrestha PM Minimally invasive plate osteosynthesis with locking compression plate for distal diametaphyseal tibia fracture Kathmandu Univ Med J 2011

hong et al

Fractures of the Distal Tibia Treated with PolyaxialLocking Plating

Hong Gao MD Chang-Qing Zhang MD PhD Cong-FengLuo MD PhD Zu-Bin Zhou MD and Bing-Fang Zeng

MDClin Orthop Relat Res 2009 March 467(3) 831ndash837 Total pts 32 The average healing time was 13 weeks (range 10ndash18 weeks)

for fractures using the MIPO technique and 156 weeks (range 10ndash20 weeks p = 00045) for fractures using the ORIF technique

The fracture healing time was shorter in the MIPO technique group than in the ORIF technique group which might be related to minimizing soft tissue trauma to the injured zone and preserving better blood supply around the fracture area

Bahari S et al (2007)

42 (open fracture 8)

MIPO Union 42 (224 wks)

No malunionSuperficial wound infection 2 Deep infection 1 Implant failure 1

Collinge C et al(2010)

38 (open fracture 8)

MIPO Union 38 (21 wks range 9ndash48)

Malunion ( ge 5degdeformity) 1 Secondary procedure 3

Mushtaq A et al (2009)

21 (open fracture 4)

MIPO Union 21( 55 months range 3ndash13)

Delayed union 1 Non union 1 Wound infection 2 Secondary procedure 2

Bahari S LenehanB Khan H Mcelwain JP Minimally invasive percutaneous plate fixation of distal tibia fractures Acta Orthop Belg2007

Collinge C Protzman R Outcomes of minimally invasive plate osteosynthesis for metaphyseal distal tibia fractures J OrthopTrauma 2010

Mushtaq A Shahid R AsifM Maqsood M Distal tibialfracture fixation with locking compression plate (LCP) using the minimally invasive percutaneousosteosynthesis (MIPO) technique Eur J Trauma Emerg Surg 2009

Lau TW et al (2008)

48 (open fracture 9)

MIPO Union 47 ( 187 wks range 12-44 wks)

Delayed union 5 Wound infection 8 Secondary procedure1

Gupta RK et al(2010)

80 (open fracture19)

MIPO Union 77 (19 wks range 16-32)

Delayed union 7 Non union 3 Malunion (ge 5degdeformity or ge 1 cm LLD) 2 Wound infection1 Wound breakdown 2 Secondary procedure 2

Lau TW Leung F Chan CF Chow SP Wound complication of minimally invasive plate osteosynthesis in distal tibia fractures Inter Orthop 2008

Gupta RK RohillaRK Sangwan K Singh V Walia S Locking plate fixation in distal metaphysealtibial fractures series of 79 patients Inter Orthop 2010

Shreshta et al(2011)

20 MIPO Union 20 (185 wks range 14-28)

Delayed union 1 No malunion (ge 5deg deformity or ge 1 cm LLD) Superficial wound infection 2 Deep infection 1 Secondary procedure 1

Oog Jin et al 10 MIPO Union10(21 wksrange17-28)

no non-union no angular deformity gt 5deg shortening gt 10 mm no infection

Shrestha D Acharya BM Shrestha PM Minimally invasive plate osteosynthesis with locking compression plate for distal diametaphyseal tibia fracture Kathmandu Univ Med J 2011

hong et al

Fractures of the Distal Tibia Treated with PolyaxialLocking Plating

Hong Gao MD Chang-Qing Zhang MD PhD Cong-FengLuo MD PhD Zu-Bin Zhou MD and Bing-Fang Zeng

MDClin Orthop Relat Res 2009 March 467(3) 831ndash837 Total pts 32 The average healing time was 13 weeks (range 10ndash18 weeks)

for fractures using the MIPO technique and 156 weeks (range 10ndash20 weeks p = 00045) for fractures using the ORIF technique

The fracture healing time was shorter in the MIPO technique group than in the ORIF technique group which might be related to minimizing soft tissue trauma to the injured zone and preserving better blood supply around the fracture area

Lau TW et al (2008)

48 (open fracture 9)

MIPO Union 47 ( 187 wks range 12-44 wks)

Delayed union 5 Wound infection 8 Secondary procedure1

Gupta RK et al(2010)

80 (open fracture19)

MIPO Union 77 (19 wks range 16-32)

Delayed union 7 Non union 3 Malunion (ge 5degdeformity or ge 1 cm LLD) 2 Wound infection1 Wound breakdown 2 Secondary procedure 2

Lau TW Leung F Chan CF Chow SP Wound complication of minimally invasive plate osteosynthesis in distal tibia fractures Inter Orthop 2008

Gupta RK RohillaRK Sangwan K Singh V Walia S Locking plate fixation in distal metaphysealtibial fractures series of 79 patients Inter Orthop 2010

Shreshta et al(2011)

20 MIPO Union 20 (185 wks range 14-28)

Delayed union 1 No malunion (ge 5deg deformity or ge 1 cm LLD) Superficial wound infection 2 Deep infection 1 Secondary procedure 1

Oog Jin et al 10 MIPO Union10(21 wksrange17-28)

no non-union no angular deformity gt 5deg shortening gt 10 mm no infection

Shrestha D Acharya BM Shrestha PM Minimally invasive plate osteosynthesis with locking compression plate for distal diametaphyseal tibia fracture Kathmandu Univ Med J 2011

hong et al

Fractures of the Distal Tibia Treated with PolyaxialLocking Plating

Hong Gao MD Chang-Qing Zhang MD PhD Cong-FengLuo MD PhD Zu-Bin Zhou MD and Bing-Fang Zeng

MDClin Orthop Relat Res 2009 March 467(3) 831ndash837 Total pts 32 The average healing time was 13 weeks (range 10ndash18 weeks)

for fractures using the MIPO technique and 156 weeks (range 10ndash20 weeks p = 00045) for fractures using the ORIF technique

The fracture healing time was shorter in the MIPO technique group than in the ORIF technique group which might be related to minimizing soft tissue trauma to the injured zone and preserving better blood supply around the fracture area

Shreshta et al(2011)

20 MIPO Union 20 (185 wks range 14-28)

Delayed union 1 No malunion (ge 5deg deformity or ge 1 cm LLD) Superficial wound infection 2 Deep infection 1 Secondary procedure 1

Oog Jin et al 10 MIPO Union10(21 wksrange17-28)

no non-union no angular deformity gt 5deg shortening gt 10 mm no infection

Shrestha D Acharya BM Shrestha PM Minimally invasive plate osteosynthesis with locking compression plate for distal diametaphyseal tibia fracture Kathmandu Univ Med J 2011

hong et al

Fractures of the Distal Tibia Treated with PolyaxialLocking Plating

Hong Gao MD Chang-Qing Zhang MD PhD Cong-FengLuo MD PhD Zu-Bin Zhou MD and Bing-Fang Zeng

MDClin Orthop Relat Res 2009 March 467(3) 831ndash837 Total pts 32 The average healing time was 13 weeks (range 10ndash18 weeks)

for fractures using the MIPO technique and 156 weeks (range 10ndash20 weeks p = 00045) for fractures using the ORIF technique

The fracture healing time was shorter in the MIPO technique group than in the ORIF technique group which might be related to minimizing soft tissue trauma to the injured zone and preserving better blood supply around the fracture area

hong et al

Fractures of the Distal Tibia Treated with PolyaxialLocking Plating

Hong Gao MD Chang-Qing Zhang MD PhD Cong-FengLuo MD PhD Zu-Bin Zhou MD and Bing-Fang Zeng

MDClin Orthop Relat Res 2009 March 467(3) 831ndash837 Total pts 32 The average healing time was 13 weeks (range 10ndash18 weeks)

for fractures using the MIPO technique and 156 weeks (range 10ndash20 weeks p = 00045) for fractures using the ORIF technique

The fracture healing time was shorter in the MIPO technique group than in the ORIF technique group which might be related to minimizing soft tissue trauma to the injured zone and preserving better blood supply around the fracture area

ADVANTAGE OF MIPPO OVER

ORIF

mipo orif

Smaller incision

Fracture site is undisturbed

Better callus formation

Blood supply to fracture fragments maintained

Larger incision

Fracture site explored

Callus formation is delayed

Blood supply is hampered

mipo orif

Low infection rate due to smaller incision and decrease soft tisuedamage

decreased need for bone grafting

High infection rate due to poor soft tissue handling over large incised wound

Bone grafting is required sometimes

conclusion

Minimally invasive plate osteosynthesis(MIPO) of the distal tibia offers several theoretical advantages compared to classic open reduction and internal fixation A mechanically stable fracture-bridging osteosynthesis can be obtained without significant dissection and surgical trauma to the bone and surrounding soft tissues

MIPO has a high union rate and less complication rate

Thank you

mipo orif

Smaller incision

Fracture site is undisturbed

Better callus formation

Blood supply to fracture fragments maintained

Larger incision

Fracture site explored

Callus formation is delayed

Blood supply is hampered

mipo orif

Low infection rate due to smaller incision and decrease soft tisuedamage

decreased need for bone grafting

High infection rate due to poor soft tissue handling over large incised wound

Bone grafting is required sometimes

conclusion

Minimally invasive plate osteosynthesis(MIPO) of the distal tibia offers several theoretical advantages compared to classic open reduction and internal fixation A mechanically stable fracture-bridging osteosynthesis can be obtained without significant dissection and surgical trauma to the bone and surrounding soft tissues

MIPO has a high union rate and less complication rate

Thank you

mipo orif

Low infection rate due to smaller incision and decrease soft tisuedamage

decreased need for bone grafting

High infection rate due to poor soft tissue handling over large incised wound

Bone grafting is required sometimes

conclusion

Minimally invasive plate osteosynthesis(MIPO) of the distal tibia offers several theoretical advantages compared to classic open reduction and internal fixation A mechanically stable fracture-bridging osteosynthesis can be obtained without significant dissection and surgical trauma to the bone and surrounding soft tissues

MIPO has a high union rate and less complication rate

Thank you

conclusion

Minimally invasive plate osteosynthesis(MIPO) of the distal tibia offers several theoretical advantages compared to classic open reduction and internal fixation A mechanically stable fracture-bridging osteosynthesis can be obtained without significant dissection and surgical trauma to the bone and surrounding soft tissues

MIPO has a high union rate and less complication rate

Thank you

Thank you